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Adapted from the World Health Organization by the Department of Health with support from: JICA, UNFPA, and UNICEF
WHO Library Cataloguing-in-Publication Data Pregnancy, childbirth, postpartum and newborn care : a guide for essential practice. At head of title: Integrated Management of Pregnancy and Childbirth. 1.Labor, Obstetric 2.Delivery, Obstetric 3.Prenatal care 4.Perinatal care methods 5.Postnatal care - methods 6.Pregnancy complications - diagnosis 7.Pregnancy complications - therapy 8.Manuals I.World Health Organization. ISBN 92 4 159084 X (NLM classification: WQ 175)
World Health Organization 2003 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination,World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed in the Philippines
FOREWORD
Maternal and newborn health has long been a priority area of concern and activity of the Department of Health. In order for gains in womens health to be sustainable, capacity and capability development is the key. The Department of Health is proud to present and adapt this manual, The Essential Care Practice Guideline for Pregnancy, Childbirth, Post-partum, and Newborn Care, as part of its continuing commitment to learning and sharing lessons and best practices for developing human and institutional capacity in the field of emergency obstetrics. This is a technical document with a development aim. In its technical sense, the manual provides evidence-based recommendations to guide health care professionals in the management of women during pregnancy, childbirth and postpartum, post abortion, and newborns during their first week of life. All recommendations are for skilled birth attendants working as a team at the primary level of health care, either at the facility or in the community. They apply to all women attending antenatal care, in delivery, postpartum or post abortion care, or who come for emergency care, and to all newborns at birth and during the first week of life. But its broader purpose is to develop and enhance the ability of people in the facility and the community in provinces and regions with high maternal mortality in order to identify key challenges and generate effective responses to them. The manual offers a way of thinking on decision making, rather than just a set of instructions on how to do it. In both its form and its function, the manual is about building capacity and capability. At another level, of course, the manual is about improving the health of women. Women are crucial to the social and economic development of their societies, as members of the work force and the backbone of households. They are the creators of new life, and the caretakers of daily life. Although saving a womans life has tremendous benefits for her family and her community, it is the horrible and needless deaths of the women themselves that is our call to action. The technology to avert maternal deaths has been known for decades, yet it is still unavailable to large numbers of women in developing countries. The strategies and instruments presented in this manual were developed by the World Health Organization and pilot-tested by the Safe Motherhood Program of the Department of Health in cooperation with JICA, UNICEF, UNFPA, CHD-NCR, CHD-8 and other stakeholders. It should be noted that some sections were modified to suit local needs and resources (i.e. Philippine Guidelines on Gestational Diabetes). This manual is intended for doctors, nurses and midwives who work as a team at the primary level of health care. Since its inception 2 years ago, the manual have embodied many of the concepts currently practiced in obstetrics and gynecology and newborn care at the local setting. In fact, the experience of the Department of Health in the launching and pilot-testing of the manual represents one of the departments great success stories in capacity and capabilty development. The DOH would like to thank the following organizations who are responsible for the review of the different chapters of this manual: Philippine Pediatric Society, Philippine Obstetrical and Gynecological Society and Jose Fabella Memorial Hospital.
FOREWORD
Foreword
Acknowledgments
ACKNOWLEDGMENTS
ACKNOWLEDGMENTS
This manual was reviewed and revised in the context of the Philippine setting by a team composed of the following members: Dr. Ma. Lu Andal Dr. Juanita Basilio Dr. Ma. Elizabeth Caluag Dr. Martha Cayad-an Dr. Diego Danila Ms. Elizabeth Dumaran Dr. Mario Festin Dr. Josephine Hipolito Dr. Jojie Ilagan Dr. Carol Mirano Dr. Aurora Musngi Dr. Dolores Belmonte-Sy -Jose Fabella Memorial Hospital -Department of Health -Department of Health -UNICEF -Department of Health -Department of Health-NCR -UP-NIH, POGS -Department of Health -Department of Health -Jose Fabella Memorial Hospital -Jose Fabella Memorial Hospital -Perinatal Association of the Philippines
Valuable technical assistance was provided by the Center for Reproductive Health Leadership and Development, Inc. (CRHLD) in the finalization and production of this manual. Finally, the Department of Health acknowledges the support provided by Japan International Cooperation Agency (JICA), United Nations Childrens Emergency Fund (UNICEF), United Nations Population Fund (UNFPA) and World Health Organization (WHO).
ACKNOWLEDGEMENTS
TABLE OF CONTENTS
TRODUCTION
INTRODUCTION
Introduction How to read the Guide Content Structure and presentation Assumptions underlying the guide
A
A2 A3 A4 A5
Communication Workplace and administrative procedures Universal precautions and cleanliness Organising a visit
QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILD BEARING AGE
TABLE OF CONTENTS
B 3 Quick check B 3 - B 7 Rapid assessment and management B 3 Airway and breathing B 3 Circulation (shock) B 4 - B 5 Vaginal bleeding B 6 Convulsions or unconscious B 6 Severe abdominal pain B 6 Dangerous fever B 7 Labour B 7 Other danger signs or symptoms B 7 If no emergency or priority signs, non urgent
Table of contents
Table of contents
TABLE OF CONTENTS
C
C2
ANTENATAL CARE
Assess the pregnant woman: pregnancy status, birth and emergency plan C3 Check for pre-eclampsia C4 Check for anaemiaD8-D9 Check for syphilis C5 Check for HIV status C6 C7 Respond to observed signs or volunteered problems If no fetal movement C7 If ruptured membranes and no labour C7 If fever or burning on urination C8 If vaginal discharge C9 C 1 0 If signs suggesting HIV infection C 1 0 If smoking, alcohol or drug abuse, or history of violence C 1 1 If cough or breathing difficulty C 1 1 If taking antituberculosis drugs C12 Give preventive measures C13 Advise and counsel on nutrition and self-care C 1 4 - C 1 5 Develop a birth and emergency plan C 1 4 Facility delivery C 1 4 Home delivery with a skilled attendant C 1 5 Advise on labour signs C 1 5 Advise on danger signs C 1 5 Discuss how to prepare for an emergency in pregnancy C16 Advise and counsel on family planning C 1 6 Counsel on the importance of family planning C 1 6 Special consideration for family planning counselling during pregnancy C17 Advise on routine and follow-up visitsD25 C18 Home delivery without a skilled attendant C18 Screening for gestational diabetes
Examine the woman in labour or with ruptured membranes D2 Decide stage of labour D3 Respond to obstetrical problems on admission D4-D5 D 6 - D 7 Give supportive care throughout labour Communication D6 Cleanliness D6 Mobility D6 Urination D6 Eating, drinking D6 Breathing technique D6 Pain and discomfort relief D6 Birth companion D7 First stage of labour D8-D9 Not in active labour D8 In active labour D9 D 1 0 - D 1 1 Second stage of labour: deliver the baby and give immediate newborn care D 1 2 - D 1 3 Third stage of labour: deliver the placenta D 1 4 - D 1 8 Respond to problems during labour and delivery D14 If fetal heart rate <120 or >160 beats per minute D15 If prolapsed cord D16 If breech presentation D17 If stuck shoulders (Shoulder dystocia) D18 If multiple births Care of the mother and newborn within first hour of delivery of placenta D19 Care of the mother one hour after delivery of placenta D20 D21 Assess the mother after delivery D 2 2 - D 2 5 Respond to problems immediately postpartum D22 If vaginal bleeding D22 If fever (temperature >38C) D22 If perineal tear or episiotomy (done for lifesaving circumstances) D23 If elevated diastolic blood pressure D24 If pallor on screening, check for anaemia D24 If mother severely ill or separated from the child D24 If baby stillborn or dead Give preventive measures D25
CHILDBIRTH LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE (CONTINUED) Advise on postpartum care D26 Advise on postpartum care and hygiene D26 Counsel on nutrition Counsel on birth spacing and family planning D27 Counsel on the importance of family planning D27 Lactation amenorrhea method (LAM) Advise on when to return D28 Routine postpartum visits D28 Follow-up visits for problems D28 Advise on danger signs D28 Discuss how to prepare for an emergency in postpartum Home delivery by skilled attendant D29 Preparation for home delivery D29 Delivery care D29 Immediate postpartum care of mother D29 Postpartum care of newborn
PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN Preventive measures Give tetanus toxoid F2 F2 Give vitamin A postpartum F2 Give iron and folic acid F3 Give mebendazole Motivate on compliance with iron treatment F3 Give preventive intermittent treatment for falciparum malaria F4 Advise to use insecticide-treated bednet F4 Give appropriate oral antimalarial treatment F4 Give paracetamol F4 Additional treatments for the woman Give appropriate oral antibiotics F5 Give benzathine penicillin IM F6 Observe for signs of allergy F6
D26
F2-F4
D27
D28
F5-F6
D29
POSTPARTUM CARE
TABLE OF CONTENTS
E2 Postpartum examination of the mother (up to 6 weeks) E 3 - E 1 0 Respond to observed signs or volunteered problems If elevated diastolic blood pressure E3 If pallor, check for anaemia E4 Check for HIV status E5 If heavy vaginal bleeding E6 If fever or foul-smelling lochia E6 If dribbling urine E7 If pus or perineal pain E7 E7 If feeling unhappy or crying easily E8 If vaginal discharge 4 weeks after delivery E8 If breast problem E9 If cough or breathing difficulty E9 If taking anti-tuberculosis drugs E 1 0 If signs suggesting HIV infection
Table of contents
Table of contents
TABLE OF CONTENTS
INFORM AND COUNSEL ON HIV Provide key information on HIV G 2 What is HIV and how is HIV transmitted? G 2 Advantage of knowing the HIV status in pregnancy G 2 Counsel on correct and consistent use of condoms Voluntary counselling and testing (VCT) services G 3 Voluntary counselling and testing services G 3 Discuss confidentiality of the result G 3 Implications of test result G 3 Benefits of involving and testing the male partner(s) Care and counselling on family planning for the HIV-positive woman G 4 Additional care for the HIV-positive woman G 4 Counsel the HIV-positive woman on family planning Support to the HIV-positive woman G 5 Provide emotional support to the woman G 5 How to provide support Prevent mother-to-child transmission of HIV G 6 Give antiretroviral drug to prevent MCTC of HIV G 6 Antiretroviral drug for prevention of MCTC of HIV Counsel on infant feeding choice G 7 Explain the risks of HIV transmission through breastfeeding and not breastfeeding G 7 If a woman has unknown or negative HIV status G 7 If a woman knows and accepts that she is HIV-positive If the mother chooses replacement feeding G 8 Teach the mother replacement feeding G 8 Explain the risks of replacement feeding G 8 Follow-up for replacement feeding G 8 Give special counselling to the mother who is HIV-positive and chooses breastfeeding
THE WOMAN WITH SPECIAL NEEDS Emotional support for the woman with special needs H 2 Sources of support H 2 Emotional support Special considerations in managing the pregnant adolescent H 3 When interacting with the adolescent H 3 Help the girl consider her options and to make decisions which best suit her needs Special considerations for supporting the woman living with violence H 4 Support the woman living with violence H 4 Support the health service response to needs of women living with violence
G2
H2
G3
H4
G4
G5
COMMUNIT Y SUPPORT FOR MATERNAL AND NEWBORN HEALTH I2 Establish links I2 Coordinate with other health care providers and community groups Establish links with traditional birth attendants and traditional I2 healers Involve the community in quality of services
G6
G7
I3
G8
J
J2
K8 NEWBORN CARE Examine the newborn If preterm, birth weight <2500 g or twin J3 J 4 Assess breastfeeding J 5 Check for special treatment needs J 6 Look for signs of jaundice and local infection J 7 If danger signs J 8 If swelling, bruises or malformation J9 Assess the mothers breasts if complaining of nipple or breast pain Care of the newborn Additional care of a small baby (or twin) Perform newborn screening BREASTFEEDING, CARE, PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN Counsel on breastfeeding K 2 Counsel on importance of exclusive breastfeeding K 2 Help the mother to initiate breastfeeding K 3 Support exclusive breastfeeding K 3 Teach correct positioning and attachment for breastfeeding K 4 Give special support to breastfeed the small baby (preterm and/or low birth weight) K 4 Give special support to breastfeed twins Alternative feeding methods K 5 Express breast milk K 5 Hand express breast milk directly into the babys mouth K 6 Cup feeding expressed breast milk K 6 Quantity to feed by cup K 6 Signs that baby is receiving adequate amount of milk Weigh and assess weight gain K 7 Weigh baby in the first month of life K 7 Assess weight gain K 7 Scale maintenance
K9
K10
K11
K
K2
K12
K5
TABLE OF CONTENTS
K7
K14
Other breastfeeding support K 8 Give special support to the mother who is not yet breastfeeding K 8 If the baby does not have a mother K 8 Advise the mother who is not breastfeeding at all on how to relieve engorgement Ensure warmth for the baby K 9 Keep the baby warm K 9 Keep a small baby warm K 9 Rewarm the baby skin-to-skin Other baby care K10 Cord care K10 Sleeping K10 Hygiene Newborn resuscitation K11 Keep the baby warm K11 Open the airway K11 If still not breathing, ventilate K11 If breathing less than 30 breaths per minute or severe chest in-drawing, stop ventilating K11 If not breathing or gasping at all after 20 minutes of ventilation Treat and immunize the baby K12 Treat the baby K12 Give 2 IM antibiotics (first week of life) K12 Give IM benzathine penicillin to baby (single dose) if mother tested RPR-positive K12 Give IM antibiotic for possible gonococcal eye infection (single dose) K13 Treat local infection K13 Give isoniazid (INH) prophylaxis to newborn K13 Immunize the newborn Advise when to return with the baby K14 Routine visits K14 Follow-up visits K14 Advise the mother to seek care for the baby K14 Refer baby urgently to hospital
Table of contents
Table of contents
TABLE OF CONTENTS
L
L2 L3 L4 L5
EQUIPMENT, SUPPLIES, DRUGS AND LABORATORY TESTS Equipment, supplies, drugs and tests for pregnancy and postpartum care Equipment, supplies and drugs for childbirth care Laboratory tests Check urine for protein L4 L4 Check haemoglobin Perform rapid plamareagin (RPR) test for syphilis L5 M7Interpreting results INFORMATION AND COUNSELLING SHEETS Care during pregnancy Preparing a birth and emergency plan Care for the mother after birth Care after an abortion Care for the baby after birth Breastfeeding M8-M9 Clean home delivery RECORDS AND FORMS Referral record Feedback record Labour record Partograph Postpartum record Form of medical certificate of cause of death SSARY AND ACRONYMS GLOSSARY AND ACRONYMS
M
M2 M3 M4 M5 M6 M7
N
N2 N3 N4 N5 N6 N7
INTRODUCTION
The aim of Pregnancy, Childbirth, Postpartum and Newborn Care Guide for Essential Practice (PCPNC) is to provide evidence-based recommendations to guide health care professionals in the management of women during pregnancy, childbirth and postpartum, and post abortion, and newborns during their first week of life. All recommendations are for skilled attendants working at the primary level of health care, either at the facility or in the community. They apply to all women attending antenatal care, in delivery, postpartum or post abortion care, or who come for emergency care, and to all newborns at birth and during the first week of life (or later) for routine and emergency care. The PCPNC is a Guide for clinical decision-making. It facilitates the collection, analysis, classification and use of relevant information by suggesting key questions, essential observations and/or examinations, and recommending appropriate research-based interventions. It promotes the early detection of complications and the initiation of early and appropriate treatment, including timely referral, if necessary. Correct use of this Guide should help reduce the high maternal and perinatal mortality and morbidity rates prevalent in many parts of the developing world, thereby making pregnancy and childbirth safer. The first section, How to use the guide, describes how the guide is organized, the overall content and presentation. Each chapter begins with a short description of how to read and use it, to help the reader use the guide correctly. The Guide has been developed by the Department of Reproductive Health and Research WHO and adapted to Philippine setting. Additional Guidelines that were added are the following: 1. Diabetes Protocol 2. Newborn Screening
INTRODUCTION
Introduction
Content
The Guide includes routine and emergency care for women and newborns during pregnancy, labour and delivery, postpartum and post abortion, as well as key preventive measures required to reduce the incidence of endemic and other diseases which add to maternal and perinatal morbidity and mortality. Most women and newborns using the services described in the Guide are not ill and/or do not have complications. They are able to wait in line when they come for a scheduled visit. However, the small proportion of women/newborns who are ill, have complications or are in labour, need urgent attention and care. The clinical content is divided into six sections which are as follows: Quick check (triage), emergency management (called Rapid Assessment and Management or RAM) and referral, followed by a chapter on emergency treatments for the woman. Post-abortion care. Antenatal care. Labour and delivery. Postpartum care. Newborn care.
In each of the six clinical sections listed above there is a series of flow, treatment and information charts which include: Guidance on routine care, including monitoring the well-being of the mother and/or baby. Early detection and management of complications. Preventive measures. Advice and counselling. In addition to the clinical care outlined above, other sections in the guide include: Advice on HIV. Support for women with special needs. Links with the community. Drugs, supplies, equipment, universal precautions and laboratory tests. Examples of clinical records. Counselling and key messages for women and families.
There is an important section at the beginning of the Guide entitled Principles of good care . This includes principles of good care for all women, including those with special needs. It explains the organization of each visit to a healthcare facility, which applies to overall care. The principles are not repeated for each visit. Recommendations for the management of complications at secondary (referral) health care level can be found in the following guides for midwives and doctors: Managing complications of pregnancy and childbirth (WHO/RHR/00.7) Managing newborn problems. These and other documents referred to in this Guide can be obtained from the Department of Health, National Center for Disease Prevention and Control.
Flow charts
3
ASK CHECK RECORD LOOK, LISTEN, FEEL SIGNS
6 7 8
detailed to include in the flow charts: Treatments. Colour is used in the flow charts to indicate The flow charts include the following the severity of a condition. Advice and counselling. information: 6. Green usually indicates no abnormal 1. Key questions to be asked. Preventive measures. 2. Important observations and examinations condition and therefore normal care is given, Relevant procedures. as outlined in the guide, with appropriate to be made. advice for home care and follow up. 3. Possible findings (signs) based on 7. Yellow indicates that there is a problem information elicited from the questions, Information and counselling that can be treated without referral. observations and, where appropriate, sheets 8. Red highlights an emergency which examinations. requires immediate treatment and, in most These contain appropriate advice and 4. Classification of the findings. cases, urgent referral to a higher level health counselling messages to provide to the 5. Treatment and advice related to the woman, her partner and family. In addition, a facility. signs and classification. section is included at the back of the Guide to support the skilled attendant in this effort. Treat, advise means giving the treatment Key sequential steps Individual sheets are provided with simplified indicated (performing a procedure, versions of the messages on care during The charts for normal and abnormal prescribing drugs or other treatments, pregnancy (preparing a birth and emergency deliveries are presented in a framework of advising on possible side-effects and how plan, clean home delivery, care for the mother key sequential steps for a clean safe to overcome them) and giving advice on and baby after delivery, breastfeeding and care delivery. The key sequential steps for other important practices.The treat and after an abortion) to be given to the mother, her delivery are in a column on the left side of advise column is often crossreferenced partner and family at the appropriate stage of the page, while the column on the right has to other treatment and/or information pregnancy and childbirth. interventions which may be required if charts.Turn to these charts for more problems arise during delivery. Interventions information. may be linked to relevant treatment and/or These sheets are presented in a generic information pages, and are cross-referenced format.They will require adaptation to local 4 conditions and language, and the addition of 5 to other parts of the Guide. CLASSIFY TREAT AND ADVISE illustrations to enhance understanding, acceptability and attractiveness. Different Treatment and information programmes may prefer a different format such as a booklet or flip chart. pages The flow charts are linked (cross-referenced) to relevant treatment and/or information pages in other parts of the Guide. These pages include information which is too
Use of colour
Comm
PRINCIPLES OF GOOD CARE
A2 COMMUNICATION These principles of good care apply to all contacts between the skilled attendant and all women and their babies; they are not repeated in each section. Care-givers should therefore familiarize themselves with the following principles before using the Guide. The principles concern: Communication A2 . Workplace and administrative procedures A3 . Universal precautions and cleanliness A4 . Organizing a visit A5 .
A5 ORGANIZING A VISIT
A5
A1
Communication
PRINCIPLES OF GOOD CARE
A2
COMMUNICATION
Communicating with the woman (and her companion)
Make the woman (and her companion) feel welcome. Be friendly, respectful and non-judgmental at all times. Use simple and clear language. Encourage her to ask questions. Ask and provide information related to her needs. Support her in understanding her options and making decisions. At any examination or before any procedure: seek her permission and inform her of what you are doing. Summarize the most important information, including the information on routine laboratory tests and treatments. Verify that she understands emergency signs, treatment instructions, and when and where to return. Check for understanding by asking her to explain or demonstrate treatment instructions.
Prescribing and recommending treatments and preventive measures for the woman and/or her baby
When giving a treatment (drug, vaccine, bednet, condom) at the clinic, or prescribing measures to be followed at home: Explain to the woman what the treatment is and why it should be given. Explain to her that the treatment will not harm her or her baby, and that not taking it may be more dangerous. Give clear and helpful advice on how to take the drug regularly: for example: take 2 tablets 3 times a day, thus every 8 hours, in the morning, afternoon and evening with some water and after a meal, for 5 days.
Demonstrate the procedure. Explain how the treatment is given to the baby. Watch her as she does the first treatment in the clinic. Explain the side-effects to her. Explain that they are not serious, and tell her how to manage them. Advise her to return if she has any problems or concerns about taking the drugs. Explore any barriers she or her family may have, or have heard from others, about using the treatment, where possible: Has she or anyone she knows used the treatment or preventive measure before? Were there problems? Reinforce the correct information that she has, and try to clarify the incorrect information. Discuss with her the importance of buying and taking the prescribed amount. Help her to think about how she will be able to purchase this.
Universal p
WORKPLACE AND ADMINISTRATIVE PROCEDURES
Workplace
Service hours should be clearly posted. Be on time with appointments or inform the woman/women if she/they need to wait. Before beginning the services, check that equipment is clean and functioning and that supplies and drugs are in place. Keep the facility clean by regular cleaning. At the end of the service: discard litter and sharps safely prepare for disinfection; clean and disinfect equipment and supplies replace linen, prepare for washing replenish supplies and drugs ensure routine cleaning of all areas. Hand over essential information to the colleague who follows on duty.
Record keeping
Always record findings on a clinical record and home-based record. Record treatments, reasons for referral, and follow-up recommendations at the time the observation is made. Do not record confidential information on the home-based record if the woman is unwilling. Maintain and file appropriately: all clinical records all other documentation.
A3
A4
Protect yourself from blood and other body fluids during deliveries
Wear gloves; cover any cuts, abrasions or broken skin with a waterproof bandage; take care when handling any sharp instruments (use good light); and practice safe sharps disposal. Wear a long apron made from plastic or other fluid resistant material, and shoes. If possible, protect your eyes from splashes of blood. Normal spectacles are adequate eye protection.
Wash hands
Wash hands with soap and water: Before and after caring for a woman or newborn, and before any treatment procedure Whenever the hands (or any other skin area) are contaminated with blood or other body fluids After removing the gloves, because they may have holes After changing soiled bedsheets or clothing. Keep nails short.
Wear gloves
Wear sterile or highly disinfected gloves when performing vaginal examination, delivery, cord cutting, repair of episiotomy or tear, blood drawing. Wear long sterile or highly disinfected gloves for manual removal of placenta. Wear clean gloves when: Handling and cleaning instruments Handling contaminated waste Cleaning blood and body fluid spills.
Sterilize gloves
Sterilize by autoclaving or highly disinfect by steaming or boiling.
ORGANIZING A VISIT
Receive and respond immediately
Receive every woman and newborn baby seeking care immediately after arrival (or organize reception by another provider). Perform Quick Check on all new incoming women and babies and those in the waiting room, especially if no-one is receiving them B2 . At the first emergency sign on Quick Check, begin emergency assessment and management (RAM) B1-B7 for the woman, or examine the newborn J1-J11 . If she is in labour, accompany her to an appropriate place and follow the steps as in Childbirth: labour, delivery and immediate postpartum care D1-D29 . If she has priority signs, examine her immediately using Antenatal care, Postpartum or Post-abortion care charts C1-C18 E1-E10 B18-B22 . If no emergency or priority sign on RAM or not in labour, invite her to wait in the waiting room. If baby is newly born, looks small, examine immediately. Do not let the mother wait in the queue. about what you are doing. If she is unconscious, talk to the companion. Ensure and respect privacy during examination and discussion. If she came with a baby and the baby is well, ask the companion to take care of the baby during the maternal examination and treatment.
Begin each routine visit (for the woman and/or the baby)
Greet the woman and offer her a seat. Introduce yourself. Ask her name (and the name of the baby). Ask her: Why did you come? For yourself or for your baby? For a scheduled (routine) visit? For specific complaints about you or your baby? First or follow-up visit? Do you want to include your companion or other family member (parent if adolescent) in the examination and discussion? If the woman is recently delivered, assess the baby or ask to see the baby if not with the mother. If antenatal care, always revise the birth plan at the end of the visit after completing the chart. For a postpartum visit, if she came with the baby, also examine the baby: Follow the appropriate charts according to pregnancy status/age of the baby and purpose of visit. Follow all steps on the chart and in relevant boxes. Unless the condition of the woman or the baby requires urgent referral to hospital, give preventive measures if due even if the woman has a condition in yellow that requires special treatment.
Care of woman or baby referred for special care to secondary level facility
When a woman or baby is referred to a secondary level care facility because of a specific problem or complications, the underlying assumption of the Guide is that, at referral level, the woman/baby will be assessed, treated, counselled and advised on follow-up for that particular condition/ complication. Follow-up for that specific condition will be either: organized by the referral facility or written instructions will be given to the woman/baby for the skilled attendant at the primary level who referred the woman/baby. the woman/baby will be advised to go for a follow-up visit within 2 weeks according to severity of the condition. Routine care continues at the primary care level where it was initiated.
If follow-up visit is within a week, and if no other complaints: Assess the woman for the specific condition requiring follow-up only Compare with earlier assessment and reclassify. If a follow-up visit is more than a week after the initial examination (but not the next scheduled visit): Repeat the whole assessment as required for an antenatal, post-abortion, postpartum or newborn visit according to the schedule If antenatal visit, revise the birth plan.
Organizing a visit
A5
QUICK CHECK
Perform Quick check immediately after the woman arrives B2 . If any danger sign is seen, help the woman and send her quickly to the emergency room. Always begin a clinical visit with Rapid assessment and management (RAM) B3-B7 : Check for emergency signs first B3-B6 : If present, provide emergency treatment and refer the woman urgently to hospital. Complete the referral form N2 . Check for priority signs. If present, manage according to charts B7 . If no emergency or priority signs, allow the woman to wait in line for routine care, according to pregnancy status.
B3
B4 B2
B5
B6
B7
B1
Quick check
QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE
B2
QUICK CHECK
A person responsible for initial reception of women of childbearing age and newborns seeking care should: assess the general condition of the careseeker(s) immediately on arrival periodically repeat this procedure if the line is long. If a woman is very sick, talk to her companion.
SIGNS
CLASSIFY
TREAT
Transfer woman to a treatment room for Rapid assessment and management B3-B7 Call for help if needed. Reassure the woman that she will be taken care of immediately. Ask her companion to stay.
If the woman is or has: EMERGENCY unconscious (does not answer) FOR WOMAN convulsing bleeding severe abdominal pain or looks very ill headache and visual disturbance severe difficulty breathing fever severe vomiting. Imminent delivery or Labour If the baby is or has: very small convulsions difficult breathing just born any maternal concern. Pregnant woman, or after delivery, with no danger signs A newborn with no danger signs or maternal complaints. LABOUR EMERGENCY FOR BABY
Transfer the woman to the labour ward. Call for immediate assessment. Transfer the baby to the treatment room for immediate Newborn care J1-J11 Ask the mother to stay.
ROUTINE CARE
Keep the woman and baby in the waiting room for routine care.
B3 B3 .
B2
Rapid assessment and RAPID ASSESSMENT AND management MANAGEMENT (RAM) (RAM) Airway and breathing, circulation (shock)
QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE
B3
Use this chart for rapid assessment and management (RAM) of all women of childbearing age, and also for women in labour, on first arrival and periodically throughout labour, delivery and the postpartum period. Assess for all emergency and priority signs and give appropriate treatments, then refer the woman to hospital.
FIRST ASSESS
EMERGENCY SIGNS
Do all emergency steps before referral
TREATMENT MEASURE
B Manage airway and breathing B9 Refer woman urgently to hospital* B17
This may be pneumonia, severe anaemia with heart failure, obstructed breathing, asthma.
CIRCULATION (SHOCK)
Cold moist skin or Weak and fast pulse Measure blood pressure Count pulse Measure blood pressure. If systolic BP < 90 mmHg or pulse >110 per minute: Position the woman on her left side with legs higher than chest. Insert an IV line B9 Give fluids rapidly B9 If not able to insert peripheral IV, use alternative B9 Keep her warm (cover her). Refer her urgently to hospital* B17 * But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28
This may be haemorrhagic shock, septic shock.
Rapid assessment and management (RAM) Airway and breathing, circulation (shock)
B3
B4
VAGINAL BLEEDING
Assess pregnancy status Assess amount of bleeding
B9 B9 B10
PREGNANCY STATUS
EARLY PREGNANCY not aware of pregnancy, or not pregnant (uterus NOT above umbilicus)
BLEEDING
HEAVY BLEEDING Pad or cloth soaked in < 5 minutes.
TREATMENT
B15 Insert an IV line . B9 B17 Give fluids rapidly . B9 Give 0.2 mg ergometrine IM .B10 Repeat 0.2 mg ergometrine IM/IV if bleeding continues. If suspect possible complicated abortion, give appropriate IM/IV antibiotics B15 . Refer woman urgentlyB19 to hospital .B17
B19 Examine woman as on . B9 If pregnancy not likely, refer to other clinical guidelines. B3 B17 DO NOT do vaginal examination, but: Insert an IV line .B9 B9 Give fluids rapidly if heavy bleeding or shock .B3 B3 Refer woman urgently to hospital* B17 B17 DO NOT do vaginal examination, but: Insert an IV line B9 Give fluids rapidly if heavy bleeding or shock B3 Refer woman urgently to hospital* B17 * But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on D1-D28
PREGNANCY STATUS
POSTPARTUM (baby is born)
BLEEDING
HEAVY BLEEDING Pad or cloth soaked in < 5 minutes Constant trickling of blood Bleeding >250 ml or delivered outside health centre and still bleeding PLACENTA NOT DELIVERED
TREATMENT
Call for extra help. Massage uterus until it is hard and give oxytocin 10 IU IM. B10 Insert an IV line B9 and give IV fluids with 20 IU oxytocin at 60 drops/minute. B12 Empty bladder. Catheterize if necessary . B12 Check and record BP and pulse every 15 minutes and treat as on.B3 B3 B10 D12 When uterus is hard, deliver placenta by controlled cord traction.D12 B11 If unsuccessful and bleeding continues, remove placenta manually and check placenta. B11 B15 Give appropriate IM/IV antibiotics. B15 B17 If unable to remove placenta, refer woman urgently to hospital.B17 During transfer, continue IV fluids with 20 IU of oxytocin at 30 drops/minute.
This may be uterine atony, retained placenta, ruptured uterus, vaginal or cervical tear.
B9
If placenta is complete: B10 Massage uterus to express any clots. B10 B10 If uterus remains soft, give ergometrine 0.2 mg IV.B10 DO NOT give ergometrineB11 to women with eclampsia, pre-eclampsia or known hypertension. Continue IV fluids with 20 IU oxytocin/litre at 30 drops/minute. Continue massaging uterus till it is hard. If placenta is incomplete (or not available for inspection): Remove placental fragments. B11 Give appropriate IM/IV antibiotics. B15 B15 B17 If unable to remove, refer woman urgently to hospital.B17 Examine the tear and determine the degree. B12 B12 B17 If third degree tear (involving rectum or anus), refer woman urgently to hospital. B17 For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. Do not cross ankles. B12 Check after 5 minutes, if bleeding persists repair the tear. B12 Continue IV fluids with 20 units of oxytocin at 30 drops/minute. Insert second IV line. Apply bimanual uterine or aortic compression. B10 B10 Give appropriate IM/IV antibiotics. B15 B15 Refer woman urgently to hospital . B17 B17 Continue oxytocin infusion with 20 IU/litre of IV fluids at 20 drops/min for at least one hour after bleeding stops. B10 Observe closely (every 30 minutes) for 4 hours. Keep nearby for 24 hours. If severe pallor, refer to health centre. D12 Examine the woman using Assess the mother after delivery D12
IF PRESENT
HEAVY BLEEDING
CONTROLLED BLEEDING
B5
B6
TREATMENT
B9 Protect woman from fall and injury. Get help. B9 Manage airway B9 B13 After convulsion ends, help woman onto her left side. B14 Insert an IV line and give fluids slowly (30 drops/min) . B9 B14 Give magnesium sulphate .B13 If early pregnancy, give diazepam IV or rectally .B14 If diastolic BP >110mm of Hg, give antihypertensive .B14 B17 If temperature >38C, or history of fever, also give treatment for dangerous fever (below). Refer woman urgently to hospital* .B17 B14 Measure BP and temperature If diastolic BP >110mm of Hg, give antihypertensive .B14 B17 If temperature >38C, or history of fever, also give treatment for dangerous fever (below). Refer woman urgently to hospital* .B17 B9
This may be eclampsia.
DANGEROUS FEVER
Fever (temperature more than 38C) and any of: Very fast breathing Stiff neck Lethargy Very weak/not able to stand Measure temperature
B9 Insert an IV line and give fluids . B9 B17 If temperature more than 38C, give first dose of appropriate IM/IV B3 antiobiotics .B15 Refer woman urgently to hospital* .B17 If systolic BP <90 mm Hg see B3 B9 B9 B15 Insert an IV line . B9 B16 Give fluids slowly .B9 B17 Give first dose of appropriate IM/IV antibiotics . B15 Give artemether IM (if not available, give quinine IM) and glucose. B16 Refer woman urgently to hospital.* B17 * But if birth is imminent (bulging, thin perineum during contractions, visible
This may be ruptured uterus, obstructed labour, abruptio placenta, puerperal or postabortion sepsis, ectopic pregnancy.
NEXT:assessment Priority signs Rapid and management (RAM) > Emergency signs fetal head), transfer woman to labour room and proceed as on D1-D28 . D1-D28
B6
PRIORITY SIGNS
QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE
MEASURE
TREATMENT
Manage as for Childbirth. D1-D28
LABOUR
Labour pains or Ruptured membranes
B19
C1-C18
B7
B8
B17 This section has details on emergency treatments identified during Rapid assessment and management (RAM) B3-B6 to be given before referral. Give the treatment and refer the woman urgently to hospital .B17 B15 INFECTION
Give appropriate IV/IM antibiotics
If drug treatment, give the first dose of the drugs before referral. Do not delay referral by giving non-urgent treatments.
Massage uterus and expel clots Apply bimanual uterine compression Apply aortic compression Give oxytocin Give ergometrine
B16 MALARIA
Give artemether or quinine IM Give glucose IV
B9
Bleeding (1)
EMERGRNCY TREATMENTS FOR THE WOMAN
B10
Give oxytocin
If heavy postpartum bleeding Initial dose IM/IV: 10 IU IV infusion: 20 IU in 1 litre at 60 drops/min Continuing dose IM/IV: repeat 10 IU after 20 minutes if heavy bleeding persists IV infusion: 10 IU in 1 litre at 30 drops/min Maximum dose Not more than 3 litres of IV fluids containing oxytocin
Give ergometrine
If heavy bleeding in early pregnancy or postpartum bleeding (after oxytocin) but
DO NOT give if eclampsia, pre-eclampsia, or hypertension
Continuing dose IM: repeat 0.2 mg IM after 15 minutes if heavy bleeding persists
B10
Bleeding (2)
B11
Bleeding (3)
EMERGRNCY TREATMENTS FOR THE WOMAN
B12
REPAIR THE TEAR AND EMPTY BLADDER Repair the tear or episiotomy
Examine the tear and determine the degree: The tear is small and involved only vaginal mucosa and connective tissues and underlying muscles (first or second degree tear). If the tear is not bleeding, leave the wound open. The tear is long and deep through the perineum and involves the anal sphincter and rectal mucosa (third and fourth degree tear). Cover it with a clean pad and refer the woman urgently to hospital .B17 If first or second degree tear and heavy bleeding persists after applying pressure over the wound: Suture the tear or refer for suturing if no one is available with suturing skills. Suture the tear using universal precautions, aseptic technique and sterile equipment. Use a needle holder and a 21 gauge, 4 cm, curved needle. Use absorbable polyglycon suture material. Make sure that the apex of the tear is reached before you begin suturing. Ensure that edges of the tear match up well. DO NOT suture if more than 12 hours since delivery. Refer woman to hospital.
Empty bladder
If bladder is distended and the woman is unable to pass urine: Encourage the woman to urinate. If she is unable to urinate, catheterize the bladder: Wash hands Clean urethral area with antiseptic Put on clean gloves Spread labia. Clean area again Insert catheter up to 4 cm Measure urine and record amount Remove catheter.
If convulsions recur After 15 minutes, give an additional 2 g of magnesium sulphate (10 ml of 20% solution) IV over 20 minutes. If convulsions still continue, give diazepam .B14 If referral delayed for long, or the woman is in late labour, continue treatment: Give 5 g of 50% magnesium sulphate solution IM with 1 ml of 2% lignocaine every 4 hours in alternate buttocks until 24 hours after birth or after last convulsion (whichever is later). Monitor urine output: collect urine and measure the quantity. Before giving the next dose of magnesium sulphate, ensure: knee jerk is present urine output >100 ml/4 hrs respiratory rate >16/min. DO NOT give the next dose if any of these signs: knee jerk absent urine output <100 ml/4 hrs respiratory rate <16/min. Record findings and drugs given.
IM IV
5g 4g 2g
10 ml and 1 ml 2% lignocaine 8 ml 4 ml
Not applicable
20 ml 10 ml
After receiving magnesium sulphate a woman feel flushing, thirst, headache, nausea or may vomit.
B13
B14
Preparation
Vial containing 500 mg as powder: to be mixed with 2.5 ml sterile water Vial containing 40 mg/ml in 2 ml Vial containing 500 mg in 100 ml Vial containing 500 mg as powder
Frequency
every 6 hours every 8 hours every 8 hours every 6 hours
Erythromycin
(if allergy to ampicillin)
B17
Infection
B15
Infection
B 15
Malaria
EMERGRNCY TREATMENTS FOR THE WOMAN
B16
Give glucose IV
If dangerous fever or very severe febrile disease treated with quinine Quinine*
2 ml vial containing 300 mg/ml 20 mg/kg 4 ml 10 mg/kg 2 ml/8 hours for a total of 7 days**
Make sure IV drip is running well. Give glucose by slow IV push. If no IV glucose is available, give sugar water by mouth or nasogastric tube. To make sugar water, dissolve 4 level teaspoons of sugar (20 g) in a 200 ml cup of clean water. * 50% glucose solution is the same as 50% dextrose solution or D50. This solution is irritating to veins. Dilute it with an equal quantity of sterile water or saline to produce 25% glucose solution.
Give the loading dose of the most effective drug, according to the national policy. If quinine: divide the required dose equally into 2 injections and give 1 in each anterior thigh always give glucose with quinine. Refer urgently to hospital .B17 If delivery imminent or unable to refer immediately, continue treatment as above and refer after delivery. * These dosages are for quinine dihydrochloride. If quinine base, give 8.2 mg/kg every 8 hours. ** Discontinue parenteral treatment as soon as woman is conscious and able to swallow. Begin oral treatment according to national guidelines.
REFER THE WOMAN URGENTLY TO THE HOSPITAL Refer the woman urgently to hospital
After emergency management, discuss decision with woman and relatives. Quickly organize transport and possible financial aid. Inform the referral centre if possible by radio or phone. Accompany the woman if at all possible, or send: a health worker trained in delivery care a relative who can donate blood baby with the mother, if possible essential emergency drugs and supplies .B17 referral note .N2 During journey: watch IV infusion if journey is long, give appropriate treatment on the way keep record of all IV fluids, medications given, time of administration and the womans condition.
Essential emergency drugs and supplies for transport and home delivery
Emergency drugs Oxytocin Ergometrine Magnesium sulphate Diazepam (parenteral) Calcium gluconate Ampicillin Gentamicin Metronidazole Ringers lactate Emergency supplies IV catheters and tubing Gloves Sterile syringes and needles Urinary catheter Antiseptic solution Container for sharps Bag for trash Torch and extra battery If delivery is anticipated on the way Soap, towels Disposable delivery kit (blade, 3 ties) Clean cloths (3) for receiving, drying and wrapping the baby Clean clothes for the baby Plastic bag for placenta Resuscitation bag and mask for the baby Strength and Form 10 IU vial 0.2 mg vial 5 g vials (20 g) 10 mg vial 1 g vial 500 mg vial 80 mg vial 500 mg vial 1 litre bottle Quantity for carry 6 2 4 3 1 4 3 2 4 (if distant referral) 2 sets 2 pairs, at least, one pair sterile 5 sets 1 1 small bottle 1 1 1
B17
B18
B19 B3-B7
B19 Always begin with Rapid assessment and management (RAM) B3-B7 . Next use the Bleeding in early pregnancy/post abortion care B19 to assess the woman with light vaginal bleeding or a history of missed periods. B21 B19 EXAMINATION OF THE WOMAN WITH BLEEDING IN EARLY PREGNANCY AND POST-ABORTION CARE Use chart on Preventive measures B20 to provide preventive B21 measures due to all women. Use Advise and counsel on post-abortion care B21 to advise on self care, danger signs, follow-up visit, family planning. Record all treatment given, positive findings, and the scheduled G1-G8 H1-H4 next visit in the home-based and clinic recording forms. B20 GIVE PREVENTIVE MEASURES G1-G8 H1-H4 If the woman is HIV positive, adolescent or has special needs, use. G1-G8 H1-H4
B21
EXAMINATION OF THE WOMAN WITH BLEEDING IN EARLY PREGNANCY, AND POST-ABORTION CARE
Use this chart if a woman has vaginal bleeding in early pregnancy or a history of missed periods
SIGNS
CLASSIFY
Vaginal bleeding and any of: COMPLICATED ABORTION Foul-smelling vaginal discharge Abortion with uterine manipulation Abdominal pain/tenderness Temperature >38C. Light vaginal bleeding THREATENED ABORTION
COMPLETE ABORTION
Two or more of the following signs: abdominal pain fainting pale very weak
ECTOPIC PREGNANCY
B19
B20
If voluntary counselling and testing (VCT) status unknown, counsel C10 on VCT . G3 If known HIV-positive: give support .G6 G4 advise on opportunistic infection and need to seek medical help . C10 counsel on correct and consistent use of condoms .G4 If HIV-negative, counsel on correct and consistent use of condoms . G4 F6 If Rapid plasma reagin (RPR) positive: Treat the woman for syphilis with benzathine penicillin . F6 Advise on treating her partner. Encourage VCT . G3 Reinforce use of condoms G4 . G4
If bleeding continues: Assess and manage as in Bleeding in early pregnancy/post-abortion care. B18-B22 B18-B22 If fever, foul-smelling vaginal discharge, or abdominal pain, give first dose of appropriate IV/IM B15 antibiotics. B15 Refer woman to hospital.
B21
C1
ANTENATAL CARE
Always begin with Rapid assessment and management (RAM) B3-B7 B3-B7 . If the woman has no emergency or priority signs and has come for antenatal care, use this section for further care. Next use the Pregnancy status and birth plan chart C3 to ask the woman about her present pregnancy status, history of previous pregnancies, and check her for general danger signs. Decide on an appropriate place of birth for the woman using this chart and prepare the birth and emergency plan. The birth plan should be reviewed during every follow-up visit. Check all women for pre-eclampsia, anaemia, syphilis and HIV status according to the charts C3-C6 . In cases where an abnormal sign is identified (volunteered or observed), use the charts Respond to observed signs or volunteered problems C7-C11 to classify the condition and identify appropriate treatment(s). Give preventive measures due C12 . Develop a birth and emergency plan C14-C15 . Advise and counsel on nutrition C13 , family planning C16 , labour signs, danger signs C15 , routine and follow-up visits C17 using Information and Counselling sheets M1-M19 . Record all positive findings, birth plan, treatments given and the next scheduled visit in the homebased maternal card/clinic recording form.
If the woman is HIV positive, adolescent or has special needs, see G1-G8 H1-H4 HI-H4 G1-G8
Antenatal care
Antenatal care
ANTENATAL CARE
C2 ASSESS THE PREGNANT WOMAN: PREGNANCY STATUS, BIRTH AND EMERGENCY PLAN CHECK FOR PRE-ECLAMPSIA C8 RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (2)
If fever or burning on urination
C1
C14 DEVELOP A BIRTH AND EMERGENCY PLAN
Facility delivery Home delivery with a skilled attendant
C3
C9
C15
Advise on labour signs Advise on danger signs Discuss how to prepare for an emergency in pregnancy
C4
C10
C16
C5
CHECK FOR SYPHILIS C11 RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (5)
If cough or breathing difficulty If taking anti-tuberculosis drugs
C17
C6
C12
C18
ASSESS THE PREGNANT WOMAN: PREGNANCY STATUS, BIRTH AND EMERGENCY PLAN
Use this chart to assess the pregnant woman at each of the four antenatal care visits. During first antenatal visit, prepare a birth and emergency plan using this chart and review them during following visits. Modify the birth plan if any complications arise.
PLACE OF DELIVERY
ADVISE
Explain why delivery needs to be at referral level .C14 Develop the birth and emergency plan C14 .
Look for caesarean scar FIRST VISIT How many months pregnant are you? When was your last period? When do you expect to deliver? How old are you? Have you had a baby before? If yes: Check record for prior pregnancies or if there is no record ask about: Number of prior pregnancies/deliveries Prior caesarean section, forceps, or vacuum Prior third degree tear Heavy bleeding during or after delivery Convulsions Stillbirth or death in first day. Do you smoke, drink alcohol or use any drugs? THIRD TRIMESTER Has she been counselled on family planning? If yes, does she want tubal ligation or IUD. C16 Feel for obvious multiple pregnancy. Feel for transverse lie. Listen to fetal heart.
REFERRAL LEVEL Prior delivery by caesarean. Age less than 14 years. Transverse lie or other obvious malpresentation within one month expected delivery. Obvious multiple pregnancy. Tubal ligation or IUD desired immediately after delivery. Documented third degree tear. History of or current vaginal bleeding or other complication during this pregnancy. Last baby born dead or died in first day. More than six previous births. Prior delivery with heavy bleeding. Prior delivery with convulsions. Prior delivery by forceps or vacuum.
Explain why delivery needs to be with a skilled birth attendant, preferably at a facility. Develop the birth and emergency plan C14
Assess the pregnant woman > Pregnancy status, birth and emergency plan
C2
C3
SIGNS
CLASSIFY
SEVERE Diastolic blood pressure 110 PRE-ECLAMPSIA mmHg and 3+ proteinuria, or Diastolic blood pressure 90 mmHg on two readings and 2+ proteinuria, and any of: severe headache blurred vision epigastric pain. Diastolic blood pressure 90-110 mmHg on two readings and 2+ proteinuria. Diastolic blood pressure 90 mmHg on 2 readings. PRE-ECLAMPSIA
Revise the birth plan and refer to hospital Advise to reduce workload and to rest. Advise on danger signs .C15 Reassess at the next antenatal visit or in 1 week if >8 months pregnant. If hypertension persists after 1 week or at next visit, refer to hospital or discuss case with the doctor or midwife, if available. NO HYPERTENSION No treatment required.
C5
CHECK FOR ANAEMIA
Screen all pregnant women at every visit.
SIGNS
Haemoglobin <7 g/dl. AND/OR Severe palmar and conjunctival pallor or Any pallor with any of >30 breaths per minute tires easily breathlessness at rest +/- dizziness HR+ >100 Haemoglobin 7-11 g/dl. OR Palmar or conjunctival pallor. +/- dizziness HR+ >100
CLASSIFY
SEVERE ANAEMIA
MODERATE ANAEMIA
NO CLINICAL ANAEMIA
C4
C5
TEST RESULT
RPR test positive.
CLASSIFY
POSSIBLE SYPHILIS
NO SYPHILIS
C7
TEST RESULT
Known HIV-positive.
CLASSIFY
HIV-POSITIVE
Known HIV-negative.
HIV-NEGATIVE
C6
C7
SIGNS
No fetal movement. No fetal heart beat.
CLASSIFY
PROBABLY DEAD BABY
No fetal movement but fetal heart WELL BABY beat present. Fever 38C. Foul-smelling vaginal discharge. Rupture of membranes at <8 months of pregnancy. Rupture of membranes at >8 months of pregnancy. UTERINE AND FETAL INFECTION RISK OF UTERINE AND FETAL INFECTION RUPTURE OF MEMBRANES
SIGNS
Fever >38C and any of: very fast breathing or stiff neck lethargy very weak/not able to stand. Fever >38C and any of: Flank pain Burning or pain on urination. Fever >38C or history of fever (in last 48 hours). Burning on urination or pain at end of urination.
CLASSIFY
VERY SEVERE FEBRILE DISEASE
C8
C9
TREAT AND ADVISE
Give appropriate oral antibiotics to woman . F5 Treat partner with appropriate oral antibiotics . F5 Advise on correct and consistent use of condoms . G2 Give clotrimazole . F5 Advise on correct and consistent use of condoms .F4 Give metronidazole to woman . F5 Advise on correct and consistent use of condoms G2 .
SIGNS
Abnormal vaginal discharge. Partner has urethral discharge or burning on passing urine. Curd like vaginal discharge. Intense vulval itching. Abnormal vaginal discharge
CLASSIFY
POSSIBLE GONORRHOEA OR CHLAMYDIA INFECTION POSSIBLE CANDIDA INFECTION POSSIBLE BACTERIAL OR TRICHOMONAS INFECTION
ASK, CHECK RECORD LOOK, LISTEN, FEEL IF SIGNS SUGGESTING HIV INFECTION
(HIV status unknown or known HIV-positive)
Have you lost weight? Do you have fever? How long (>1 month)? Have you got diarrhoea (continuous or intermittent)? How long, >1 month? Have you had cough? How long, >1 month? Assess if in high risk group: Occupational exposure? Is the woman commercial sex worker? Intravenous drug abuse? History of blood transfusion? Illness or death from AIDS in a sexual partner? Look for visible wasting. Look for ulcers and white patches in the mouth (thrush). Look at the skin: Is there a rash? Are there blisters along the ribs on one side of the body?
SIGNS
CLASSIFY
Two of these signs: STRONG LIKELIHOOD OF weight loss HIV INFECTION fever >1 month diarrhoea >1month. OR One of the above signs and one or more other signs or from a risk group.
Reinforce the need to know HIV status and advise where to go for VCT . G2-G3 Counsel on the benefits of testing the partner . G3 Advise on correct and consistent use of condoms .G2 Examine further and manage according to national HIV guidelines or refer to appropriate HIV services. Refer to TB centre if cough.
C10
C11
TREAT AND ADVISE
Give first dose of appropriate IM/IV antibiotics .B15 Refer urgently to hospital .B17
ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS IF COUGH OR BREATHING DIFFICULTY
How long have you been coughing? How long have you had difficulty in breathing? Do you have chest pain? Do you have any blood in sputum? Do you smoke? Look for breathlessness. Listen for wheezing. Measure temperature.
CLASSIFY
At least 2 of the following signs: POSSIBLE PNEUMONIA Fever >38C. Breathlessness. Chest pain. At least 1 of the following signs: POSSIBLE CHRONIC Cough or breathing difficulty LUNG DISEASE for >2 weeks Blood in sputum Wheezing Fever <38C, and Cough <2 weeks. UPPER RESPIRATORY TRACT INFECTION
Refer to hospital for assessment. If severe wheezing, refer urgently to hospital. Sputum examination
Advise safe, soothing remedy. If smoking, counsel to stop smoking. Sputum examination
C12
C13
Counsel on nutrition
Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to help her feel well and strong (give examples of types of food and how much to eat). Spend more time on nutrition counselling with very thin women and adolescents. Determine if there are important taboos about foods which are nutritionally important for good health. Advise the woman against these taboos. Talk to family members such as the partner and mother-in-law, to encourage them to help ensure the woman eats enough and avoids hard physical work
Facility delivery
Explain why birth in a facility is recommended Any complication can develop during delivery - they are not always predictable. A facility has staff, equipment, supplies and drugs available to provide best care if needed, and a referral system. Advise how to prepare Review the arrangements for delivery: How will she get there? Will she have to pay for transport? How much will it cost to deliver at the facility? How will she pay? Can she start saving straight away? Who will go with her for support during labour and delivery? Who will help while she is away to care for her home and other children? Advise when to go If the woman lives near the facility, she should go at the first signs of labour. If living far from the facility, she should go 2-3 weeks before baby due date and stay either at the maternity waiting home or with family or friends near the facility. Advise to ask for help from the community, if needed. I2 Advise what to bring Home-based maternal record. Clean cloths for washing, drying and wrapping the baby. Additional clean cloths to use as sanitary pads after birth. Clothes for mother and baby. Food and water for woman and support person.
C14
C15
Discuss how to prepare for an emergency in pregnancy
Discuss emergency issues with the woman and her partner/family: where will she go? how will they get there? how much it will cost for services and transport? can she start saving straight away? who will go with her for support during labour and delivery? who will care for her home and other children? Advise the woman to ask for help from the community, if needed .I1-I3 Advise her to bring her home-based maternal record to the health centre, even for an emergency visit.
ADVISE AND COUNSEL ON FAMILY PLANNING Counsel on the importance of family planning
If appropriate, ask the woman if she would like her partner or another family member to be included in the counselling session. Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as four weeks after delivery. Therefore it is important to start thinking early on about what family planning method they will use. Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 3 years between pregnancies is healthier for the mother and child. Information on when to start a method after delivery will vary depending whether a woman is breastfeeding or not. Make arrangements for the woman to see a family planning counsellor, or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). Advise on correct and consistent use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. Promote especially if at risk for STI or HIV .G4 For HIV-positive women, see G5 for family planning considerations Her partner can decide to have a vasectomy (male sterilization) at any time. Method options for the non-breastfeeding woman Can be used immediately postpartum Condoms Progestogen-only oral contraceptives Progestogen-only injectables Implant Spermicide Female sterilization (within 7 days or delay 6 weeks) IUD (within 48 hours or delay 4 weeks) Delay 3 weeks Combined oral contraceptives Combined injectables Diaphragm Fertility awareness methods
Method options for the breastfeeding woman Can be used immediately postpartum
Delay 6 weeks
Delay 6 months
Lactational amenorrhoea method (LAM) Condoms Spermicide Female sterilization (within 7 days or delay 6 weeks) IUD (within 48 hours or delay 4 weeks) Progestogen-only oral contraceptives Progestogen-only injectables Implants Diaphragm Combined oral contraceptives Combined injectables Fertility awareness methods
C16
C17
All pregnant women should have at least 4 routine antenatal visits. First antenatal contact should be as early in pregnancy as possible. During the last visit, inform the woman to return if she does not deliver within 2 weeks after the expected date of delivery. More frequent visits or different schedules may be required according to national malaria or HIV policies.
Follow-up visits
If the problem was: Hypertension Severe anaemia Return in: 1 week if >8 months pregnant 2 weeks
GESTATIONAL DIABETES*
Ask
Signs
Overweight or obesity
Classify
Low risk for gestational diabetes
(Low risk) Look for signs of maternal Maternal age of 25 years old and overweight or obesity above Family history of diabetes (first degree) (High risk) Ask family history of diabetes (first degree) and history of overweight and obesity Ask past pregnancy for difficult labor, large babies, congenital malformations and previous unexplained fetal death Look for signs of maternal overweight or obesity, polyhydramnios, signs of large baby, fetal abnormality and recurrent vaginal infections
Overweight and obesity Polyhydramnios Large fetus Fetal abnormality Recurrent vaginal infections
Advise glucose screening immediately at any time of gestation. The screening test should consist of a 50 gm oral anhydrous glucose (GCT) load followed by plasma glucose determination 1 hour later. The patient may not be fasting before the glucose load. A value of >140 mg/dl (7.8 mmol/L) 1 hour after the 50 gm load warrants the full OGTT perfomed in the fasting state.
* Diabetes in Pregnancy Philippine Society of Maternal and Fetal Medicine CPM 6th Edition 2004
Antenatal care
C18
D10 SECOND STAGE OF LABOUR: DELIVER THE BABY AND GIVE IMMEDIATE NEWBORN CARE (1) D11 SECOND STAGE OF LABOUR: DELIVER THE BABY AND GIVE IMMEDIATE NEWBORN CARE (2)
D7 BIRTH COMPANION
D19 CARE OF THE MOTHER AND NEWBORN WITHIN FIRST HOUR OF DELIVERY OF PLACENTA
D1
Always begin with Rapid assessment and management (RAM) . B3-B7 Next, use the chart on Examine the woman in labour or with ruptured membranes D2-D3 to assess the clinical situation and obstetrical history, and decide the stage of labour. If an abnormal sign is identified, use the charts on Respond to obstetrical problems on admission . D4-D5 Care for the woman according to the stage of labour and D8-D13 respond to problems during labour and delivery as on . D14-D18 Use Give supportive care throughout labour D6-D7 to provide support and care throughout labour and delivery. Record findings continually on labour record and partograph N4-N6 Keep mother and baby in labour room for one hour after delivery and use charts Care of the mother and newborn within first hour of delivery placenta on D19 Next use Care of the mother after the first hour following delivery of placenta D20 to provide care until discharge. Use chart on D25 to provide Preventive measures and Advise on postpartum care D26-D28 to advise on care, danger signs, when to seek routine or emergency care, and family planning. Examine the mother for discharge using chart on .D21 Do not discharge mother from the facility before 12 hours. If the mother is HIV-positive or adolescent, or has special needs, see G1-G8 H1-H4 If attending a delivery at the womans home, see D29
D 2
EXAMINE THE WOMAN IN LABOUR OR WITH RUPTURED MEMBRANES
First do Rapid assessment and management B B3-B7 . Then use this chart to assess the womans and fetal status and decide stage of labour.
CHILDBIRTH: LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE
D2
D3
SIGNS
Bulging thin perineum, vagina gaping and head visible, full cervical dilatation. Cervical dilatation: multigravida e5 cm primigravida e6 cm Cervical dilatation e4 cm. Cervical dilatation: 0-3 cm; contractions weak and <2 in 10 minutes.
CLASSIFY
IMMINENT DELIVERY
EARLY ACTIVE LABOUR NOT YET IN ACTIVE LABOUR See first stage of labour not active labour . D8 Record in labour record N4
SIGNS
Transverse lie. Continuous contractions. Constant pain between contractions. Sudden and severe abdominal pain. Horizontal ridge across lower abdomen. Labour >24 hours.
CLASSIFY
OBSTRUCTED LABOUR
FOR ALL SITUATIONS IN RED BELOW, REFER URGENTLY TO HOSPITAL IF IN EARLY LABOUR,MANAGE ONLY IF IN LATE LABOUR
Rupture of membranes and any of: Fever >38C Foul-smelling vaginal discharge. Rupture of membranes at <8 months of pregnancy. UTERINE AND FETAL INFECTION RISK OF UTERINE AND FETAL INFECTION Give appropriate IM/IV antibiotics . B17 If late labour, deliver and refer to hospital after delivery . B17 Plan to treat newborn . Give appropriate IM/IV antibiotics . B15 If late labour, deliver .D10-D28 Discontinue antibiotic for mother after delivery if no signs of infection. Plan to treat newborn . J5 Assess further and manage as on . D23 Manage as on . D24 Follow specific instructions (see page numbers in left column).
Diastolic blood pressure >90 mmHg. Severe palmar and conjunctival pallor and/or haemoglobin <7 g/dl. Breech or other malpresentation . Multiple pregnancy . Fetal distress . Prolapsed cord
D4
D5
CLASSIFY
RISK OF OBSTETRICAL COMPLICATION
SIGNS
Warts, keloid tissue that may interfere with delivery. Prior third degree tear. Bleeding any time in third trimester. Prior delivery by: caesarean section forceps or vacuum delivery. Age less than 14 years . Labour before 8 completed months of pregnancy (more than one month before estimated date of delivery).
PRETERM LABOUR
Reassess fetal presentation (breech more common). If woman is lying, encourage her to lie on her left side. Call for help during delivery. Conduct delivery very carefully as small baby may pop out suddenly. In particular, control delivery of the head. Prepare equipment for resuscitation of newborn . K11 Manage as on .D14 Give appropriate IM/IV antibiotics if rupture of membrane >18 hours . B15 Plan to treat the newborn . J5 Give oral fluids. If not able to drink, give 1 litre IV fluids over 3 hours . B9
Fetal heart rate <120 or >160 beats per minute. Rupture of membranes at term and before labour. If two or more of the following signs: thirsty sunken eyes dry mouth skin pinch goes back slowly. HIV test positive. Counselled on ARV treatment and infant feeding. No fetal movement, and No fetal heart beat on repeated examination
HIV-POSITIVE
Ensure that the woman takes ARV drugs as soon as labour starts . G6 Support her choice of infant feeding . G7-G8 Explain to the parents that the baby is not doing well.
Use this chart to provide a supportive, encouraging atmosphere for birth, respectful of the womans wishes.
Communication
Explain all procedures, seek permission, and discuss findings with the woman. Keep her informed about the progress of labour. Praise her, encourage and reassure her that things are going well. Ensure and respect privacy during examinations and discussions. If known HIV positive, find out what she has told the companion. Respect her wishes.
Eating, drinking
Encourage the woman to eat and drink as she wishes throughout labour. Nutritious liquid drinks are important, even in late labour. If the woman has visible severe wasting or tires during labour, make sure she eats and drinks.
Breathing technique
Teach her to notice her normal breathing. Encourage her to breathe out more slowly, making a sighing noise, and to relax with each breath. If she feels dizzy, unwell, is feeling pins-and-needles (tingling) in her face, hands and feet, encourage her to breathe more slowly. To prevent pushing at the end of first stage of labour, teach her to pant, to breathe with an open mouth, to take in 2 short breaths followed by a long breath out. During delivery of the head, ask her not to push but to breathe steadily or to pant.
Cleanliness
Encourage the woman to bathe or shower or wash herself and genitals at the onset of labour. Wash the vulva and perineal areas before each examination. Wash your hands with soap before and after each examination. Use clean gloves for vaginal examination. Ensure cleanliness of labour and birthing area(s). Clean up spills immediately. DO NOT give enema.
Mobility
Encourage the woman to walk around freely during the first stage of labour. Support the womans choice of position (left lateral, squating, kneeling, standing supported by the companion) for each stage of labour and delivery.
Urination
Encourage the woman to empty her bladder frequently. Remind her every 2 hours.
D6
Birth companion
CHILDBIRTH: LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE
D7
Birth companion
Encourage support from the chosen birth companion throughout labour. Describe to the birth companion what she or he should do: Always be with the woman. Encourage her. Help her to breathe and relax. Rub her back, wipe her brow with a wet cloth, do other supportive actions. Give support using local practices which do not disturb labour or delivery. Encourage woman to move around freely as she wishes and to adopt the position of her choice. Encourage her to drink fluids and eat as she wishes. Assist her to the toilet when needed. Ask the birth companion to call for help if: The woman is bearing down with contractions. There is vaginal bleeding. She is suddenly in much more pain. She loses consciousness or has fits. There is any other concern. Tell the birth companion what she or he SHOULD NOT DO and explain why: DO NOT encourage woman to push. DO NOT give advice other than that given by the health worker. DO NOT keep woman in bed if she wants to move around.
C 8
MONITOR EVERY 4 HOURS:
Cervical dilatation . D3 D15 Unless indicated, DO NOT do vaginal examination more frequently than every 4 hours. Temperature. Pulse B3 Blood pressure .D23
Use this chart for care of the woman when NOT IN ACTIVE LABOUR, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes.
Discharge the woman and advise her to return if: pain/discomfort increases vaginal bleeding membranes rupture. Begin plotting the partograph N5 and manage the woman as in Active labour D9
First stage of labour (1): when the woman is not in active labour
D8
D9
Partograph passes to the right of ACTION LINE. Cervix dilated 10 cm or bulging perineum.
SECOND STAGE OF LABOUR: DELIVER THE BABY AND GIVE IMMEDIATE NEWBORN CARE
Use this chart when cervix dilated 10 cm or bulging thin perineum and head visible.
CHILDBIRTH: LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE
If unable to pass urine and bladder is full, empty bladder .B12 DO NOT let her lie flat (horizontally) on her back. If the woman is distressed, encourage pain discomfort relief . D6 DO NOT urge her to push. If, after 30 minutes of spontaneous expulsive efforts, the perineum does not begin to thin and stretch with contractions, do a vaginal examination to confirm full dilatation of cervix. If cervix is not fully dilated, await second stage. Place woman on her left side and discourage pushing. Encourage breathing technique . D6 If second stage lasts for 2 hours or more without visible steady descent of the head, call for staff trained to use vacuum extractor or refer urgently to hospital .B17 If obvious obstruction to progress (warts/scarring/keloid tissue/previous third degree tear), do a generous episiotomy. DO NOT perform episiotomy routinely. D16 If breech or other malpresentation, manage as on D16
Wait until head visible and perineum distending. Wash hands with clean water and soap. Put on gloves just before delivery. See Universal precautions during labour and delivery A4
Second stage of labour: deliver the baby and give immediate newborn care (1)
D10
Second stage of labour: deliver the baby and give immediate newborn care (2)
CHILDBIRTH: LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE
D11
If cord present and loose, deliver the baby through the loop of cord or slip the cord over the babys head; if cord is tight, clamp and cut cord, then unwind. Gently wipe face clean with gauze or cloth, if necessary. If delay in delivery of shoulders: DO NOT panic but call for help and ask companion to assist Manage as in Stuck shoulders D17 If placing newborn on abdomen is not acceptable, or the mother cannot hold the baby, place the baby in a clean, warm, safe place close to the mother.
Cut cord quickly: transfer to a firm, warm surface; start Newborn resuscitation K11
If second baby, DO NOT give oxytocin now. GET HELP. Deliver the second baby. Manage as in Multiple pregnancy D18 If heavy bleeding, repeat oxytocin 10 IU IM.
If blood oozing, place a second tie between the skin and the first tie. DO NOT apply any substance to the stump. DO NOT bandage or bind the stump.
If room cool (less than 25C), use additional blanket to cover the mother and baby. If HIV-positive mother has chosen replacement feeding, feed accordingly. Check ARV treatment needed G2
D12
D13
TREAT AND ADVISE, IF REQUIRED
If heavy bleeding: Massage uterus to expel clots if any, until it is hard . B10 Give oxytocin 10 IU IM . B10 Call for help. Start an IV line , B9 add 20 IU of oxytocin to IV fluids and give at 60 drops per minute . N9 Empty the bladder .B12 If bleeding persists and uterus is soft: Continue massaging uterus until it is hard. Apply bimanual or aortic compression . B10 Continue IV fluids with 20 IU of oxytocin at 30 drops per minute. Refer woman urgently to hospital .B17 If third degree tear (involving rectum or anus), refer urgently to hospital .B17 For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. DO NOT cross ankles. Check after 5 minutes. If bleeding persists, repair the tear . B12 If blood loss H 250ml, but bleeding has stopped: Plan to keep the woman in the facility for 24 hours. Monitor intensively (every 30 minutes) for 4 hours: BP, pulse vaginal bleeding uterus, to make sure it is well contracted. Assist the woman when she first walks after resting and recovering. If not possible to observe at the facility, refer to hospital .B17
Collect, estimate and record blood loss throughout third stage and immediately afterwards.
Clean the woman and the area beneath her. Put sanitary pad or folded clean cloth under her buttocks to collect blood. Help her to change clothes if necessary. Keep the mother and baby in delivery room for a minimum of one hour after delivery of placenta. Dispose of placenta in the correct, safe and culturally appropriate manner. A4 If disposing placenta: Use gloves when handling placenta. Put placenta into a bag and place it into a leak-proof container. Always carry placenta in a leak-proof container. Bury the placenta at least 10 m away from a water source, in a 2 m deep pit.
SIGNS
CLASSIFY
PROLAPSED CORD BABY NOT WELL
BABY WELL
Respond to problems during labour and delivery (1) If FHR <120 or >160 bpm
D14
Respond to problems during labour and delivery (2) >If PROLAPSED CORD
IF PROLAPSED CORD
CHILDBIRTH: LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE
D15
The cord is visible outside the vagina or can be felt in the vagina below the presenting part.
SIGNS
Transverse lie Cord is pulsating
CLASSIFY
OBSTRUCTED LABOUR FETUS ALIVE
TREAT
Refer urgently to hospital . B17 If early labour: Push the head or presenting part out of the pelvis and hold it above the brim/pelvis with your hand on the abdomen until caesarean section is performed. Instruct assistant (family, staff) to position the womans buttocks higher than the shoulder. Refer urgently to hospital . B17 If transfer not possible, allow labour to continue. If late labour: Call for additional help if possible (for mother and baby). Prepare for Newborn resuscitation .K11 Ask the woman to assume an upright or squatting position to help progress. Expedite delivery by encouraging woman to push with contraction.
SIGNS
If early labour If late labour
TREAT
Refer urgently to hospital .B17 Call for additional help. Confirm full dilatation of the cervix by vaginal examination D3 Ensure bladder is empty. If unable to empty bladder see Empty bladder . B12 Prepare for newborn resuscitation . Deliver the baby: Assist the woman into a position that will allow the baby to hang down during delivery, for example, propped up with buttocks at edge of bed or onto her hands and knees (all fours position). When buttocks are distending, make an episiotomy. Allow buttocks, trunk and shoulders to deliver spontaneously during contractions. After delivery of the shoulders allow the baby to hang until next contraction. Place the baby astride your left forearm with limbs hanging on each side. Place the middle and index fingers of the left hand over the malar cheek bones on either side to apply gentle downwards pressure to aid flexion of head. Keeping the left hand as described, place the index and ring fingers of the right hand over the babys shoulders and the middle finger on the babys head to gently aid flexion until the hairline is visible. When the hairline is visible, raise the baby in upward and forward direction towards the mothers abdomen until the nose and mouth are free.The assistant gives supra pubic pressure during the period to maintain flexion. Feel the babys chest for arms. If not felt: Hold the baby gently with hands around each thigh and thumbs on sacrum. Gently guiding the baby down, turn the baby, keeping the back uppermost until the shoulder which was posterior (below) is now anterior (at the top) and the arm is released. Then turn the baby back, again keeping the back uppermost to deliver the other arm. Then proceed with delivery of head as described above. Tie a 1 kg weight to the babys feet and await full dilatation. Then proceed with delivery of head as described above. NEVER pull on the breech DO NOT allow the woman to push until the cervix is fully dilated. Pushing too soon may cause the head to be trapped.
D16
D17
TREAT
Call for additional help. Prepare for newborn resuscitation. Explain the problem to the woman and her companion. Ask the woman to lie on her back while gripping her legs tightly flexed against her chest, with knees wide apart. Ask the companion or other helper to keep the legs in that position. Perform an adequate episiotomy. Ask an assistant to apply continuous pressure downwards, with the palm of the hand on the abdomen directly above the pubic area, while you maintain continuous downward traction on the fetal head. Remain calm and explain to the woman that you need her cooperation to try another position. Assist her to adopt a kneeling on all fours position and ask her companion to hold her steady - this simple change of position is sometimes sufficient to dislodge the impacted shoulder and achieve delivery. Introduce the right hand into the vagina along the posterior curve of the sacrum. Attempt to deliver the posterior shoulder or arm using pressure from the finger of the right hand to hook the posterior shoulder and arm downwards and forwards through the vagina. Complete the rest of delivery as normal. If not successful, refer urgently to hospital . B17 DO NOT pull excessively on the head.
If the shoulders are still not delivered and surgical help is not available immediately.
TREAT
Prepare delivery room and equipment for birth of 2 or more babies. Include: more warm cloths two sets of cord ties and razor blades resuscitation equipment for 2 babies. Arrange for a helper to assist you with the births and care of the babies.
Deliver the first baby following the usual procedure. Resuscitate if necessary. Label her/him Twin 1. Ask helper to attend to the first baby. Palpate uterus immediately to determine the lie of the second baby. If transverse or oblique lie, gently turn the baby by abdominal manipulation to head or breech presentation. Check the presentation by vaginal examination. Check the fetal heart rate. Await the return of strong contractions and spontaneous rupture of the second bag of membranes, usually within 1 hour of birth of first baby, but may be longer. Stay with the woman and continue monitoring her and the fetal heart rate intensively. Remove wet cloths from underneath her. If feeling chilled, cover her. When the membranes rupture, perform vaginal D3 examination to check for prolapsed cord. If present, see Prolapsed cord .D15 When strong contractions restart, ask the mother to bear down when she feels ready. Deliver the second baby. Resuscitate if necessary. Label her/him Twin 2. After cutting the cord, ask the helper to attend to the second baby. Palpate the uterus for a third baby. If a third baby is felt, proceed as described above. If no third baby is felt, go to third stage of labour. DO NOT attempt to deliver the placenta until all the babies are born. DO NOT give the mother oxytocin until after the birth of all babies. Give oxytocin 10 IU IM after making sure there is not another baby. When the uterus is well contracted, deliver the placenta and membranes by controlled cord traction, applying traction to all cords together .D12-D23 Before and after delivery of the placenta and membranes, observe closely for vaginal bleeding because this woman is at greater risk of postpartum haemorrhage. If bleeding, see . B5 Examine the placenta and membranes for completeness.There may be one large placenta with 2 umbilical cords, or a separate placenta with an umbilical cord for each baby. Monitor intensively as risk of bleeding is increased. Provide immediate Postpartum care .D19-D20 In addition: Keep mother in health centre for longer observation Plan to measure haemoglobin postpartum if possible Give special support t for care and feeding of babies J11 and K4
NEXT: Care of the mother and newborn within first hour of delivery of placenta
D18
Care of the mother and newborn within first hour of delivery of placenta
CHILDBIRTH: LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE
D19
CARE OF THE MOTHER AND NEWBORN WITHIN FIRST HOUR OF DELIVERY OF PLACENTA
Use this chart for woman and newborn during the first hour after complete delivery of placenta.
INTERVENTIONS, IF REQUIRED
If pad soaked in less than 5 minutes, or constant trickle of blood, manage as on D22 If uterus soft, manage as on B10 If bleeding from a perineal tear, repair if required B12 or refer to hospital . B17
DO NOT wash away the eye antimicrobial. If blood or meconium, wipe off with wet cloth and dry. DO NOT remove vernix or bathe the baby. Continue keeping the baby warm and in skin-to-skin contact with the mother. Encourage the mother to initiate breastfeeding when baby shows signs of readiness. Offer her help. DO NOT give artificial teats or pre-lacteal feeds to the newborn: no water, sugar water, or local feeds. Examine the mother and newborn one hour after delivery of placenta. Use Assess the mother after delivery D21 and Examine the newborn . J2-J8
If breathing with difficulty grunting, chest in-drawing or fast breathing, examine the baby as on .J2-J8 If feet are cold to touch or mother and baby are separated: Ensure the room is warm. Cover mother and baby with a blanket Reassess in 1 hour. If still cold, measure temperature. If less than 36.50C, manage as on . K9 If unable to initiate breastfeeding (mother has complications): Plan for alternative feeding method . K5-K6 If mother HIV+ and chooses replacement feeding, feed accordingly . G8 If baby is stillborn or dead, give supportive care to mother and her family .D24
Refer to hospital now if woman had serious complications at admission or during delivery but was in late labour.
CARE OF MOTHER
Accompany the mother and baby to ward. Advise on Postpartum care and hygiene .D26 Ensure the mother has sanitary napkins or clean material to collect vaginal blood. Encourage the mother to eat, drink and rest. Ensure the room is warm (25C). Ask the mothers companion to watch her and call for help if bleeding or pain increases, if mother feels dizzy or has severe headaches, visual disturbance or epigastric distress.
INTERVENTIONS, IF REQUIRED
Make sure the woman has someone with her and they know when to call for help.
If heavy vaginal bleeding, palpate the uterus. If uterus not firm, massage the fundus to make it contract and expel any clots . B6 If pad is soaked in less than 5 minutes, manage as on . B5 If bleeding is from perineal tear, repair or refer to hospital . B17 If the mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is uncomfortable, help her by gently pouring water on vulva. DO NOT catheterize unless you have to. If tubal ligation or IUD desired, make plans before discharge. If mother is on antibiotics because of rupture of membranes >18 hours but shows no signs of infection now, discontinue antibiotics.
Encourage the mother to empty her bladder and ensure that she has passed urine. Check record and give any treatment or prophylaxis which is due. Advise the mother on postpartum care and nutrition . D26 Advise when to seek care .D28 Counsel on birth spacing and other family planning methods . D27 Repeat examination of the mother before discharge using Assess the mother after delivery . D21 For baby, see J2-J8
D20
D21
SIGNS
Uterus hard. Little bleeding. No perineal problem. No pallor. No fever. Blood pressure normal. Pulse normal.
CLASSIFY
MOTHER WELL
TREAT
Keep the mother at the facility for 12 hours after delivery. Ensure preventive measures .D26 Advise on postpartum care and hygiene .D26 Counsel on nutrition . D26 Counsel on birth spacing and family planning .D27 Advise on when to seek care and next routine postpartum visit .D28 Reassess for discharge .D21 Continue any treatments initiated earlier. If tubal ligation desired, refer to hospital within 7 days of delivery. If IUD desired, refer to appropriate services within 48 hours.
CLASSIFY
HEAVY BLEEDING
TREAT
See B5 for treatment. Refer urgently to hospital .B17
Encourage woman to drink plenty of fluids. Measure temperature every 4 hours. If temperature persists for >12 hours, is very high or rises rapidly, give appropriate antibiotic and B17 refer to hospital .
D22
D23
IF ELEVATED DIASTOLIC BLOOD PRESSURE ASK, CHECK RECORD LOOK, LISTEN, FEEL
If diastolic blood pressure is !!!!"90 mmHg, repeat after 1 hour rest. If diastolic blood pressure is still !!!!"90 mmHg, ask the woman if she has: severe headache blurred vision epigastric pain and check protein in urine.
SIGNS
Diastolic blood pressure !!!!!"110mmHg OR Diastolic blood pressure !!!!!"90 mmHg and 2+ proteinuria and any of: severe headache blurred vision epigastric pain.
CLASSIFY
SEVERE PRE-ECLAMPSIA
TREAT
Give magnesium sulphate . B13 If in early labour or postpartum, refer urgently to hospital . B17 If late labour: continue magnesium sulphate treatment B13 monitor blood pressure every hour. DO NOT give ergometrine after delivery. Refer urgently to hospital after delivery . B17 If early labour, refer urgently to hospital .E17 If late labour: monitor blood pressure every hour DO NOT give ergometrine after delivery. If BP remains elevated after delivery, refer to hospital .E17 Monitor blood pressure every hour. DO NOT give ergometrine after delivery. If blood pressure remains elevated after delivery, refer woman to hospital E17
Diastolic blood pressure 90- PRE-ECLAMPSIA 110 mmHg on two readings. 2+ proteinuria (on admission).
HYPERTENSION
SIGNS
Haemoglobin <7 g/dl. AND/OR Severe palmar and conjunctival pallor or Any pallor with >30 breaths per minute.
CLASSIFY
SEVERE ANAEMIA
Any bleeding. Haemoglobin 7-11 g/dl. Palmar or conjunctival pallor. Haemoglobin >11g/dl No pallor.
MODERATE ANAEMIA
DO NOT discharge before 24 hours. Check haemoglobin after 3 days. Give double dose of iron for 3 months . F3 Follow up in 4 weeks. Give iron/folate for 3 months F3
NO ANAEMIA
Teach mother to express breast milk every 3 hours K5 Help her to express breast milk if necessary. Ensure babyreceives mothers milk . K8 Help her to establish or re-establish breastfeeding as soon as possible.See . K2-K3 Give supportive care: Inform the parents as soon as possible after the babys death. Show the baby to the mother, give the baby to the mother to hold, where culturally appropriate. Offer the parents and family to be with the dead baby in privacy as long as they need. Discuss with them the events before the death and the possible causes of death. Advise the mother on breast care . K8 Counsel on appropriate family planning method .D27 Provide certificate of death and notify authorities as required N7
D24
D25
Counsel on nutrition
Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to help her feel well and strong (give examples of types of food and how much to eat). Reassure the mother that she can eat any normal foods these will not harm the breastfeeding baby. Spend more time on nutrition counselling with very thin women and adolescents. Determine if there are important taboos about foods which are nutritionally healthy. Advise the woman against these taboos. Talk to family members such as partner and mother-in-law, to encourage them to help ensure the woman eats enough and avoids hard physical work.
D26
D27
COUNSEL ON BIRTH SPACING AND FAMILY PLANNING Counsel on the importance of family planning
If appropriate, ask the woman if she would like her partner or another family member to be included in the counselling session. Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as 4 weeks after delivery. Therefore it is important to start thinking early about what family planning method they will use. Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. Information on when to start a method after delivery will vary depending on whether a woman is breastfeeding or not. Make arrangements for the woman to see a family planning counsellor, or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). Advise the correct and consistent use of condoms for dual protection from sexually transmitted infection(STI) or HIV and pregnancy. Promote their use, especially if at risk for sexually transmitted infection (STI) or HIV G2 For HIV-positive women, see G4 for family planning considerations Her partner can decide to have a vasectomy (male sterilization) at any time. Method options for the non-breastfeeding woman Can be used immediately postpartum
Delay 3 weeks
Condoms Progestogen-only oral contraceptives Progestogen-only injectables Implant Spermicide Female sterilization (within 7 days or delay 6 weeks) IUD (within 48 hours or delay 4 weeks) Combined oral contraceptives Combined injectables Diaphragm Fertility awareness methods
Method options for the breastfeeding woman Can be used immediately postpartum Lactational amenorrhoea method (LAM) Condoms Spermicide Female sterilisation (within 7 days or delay 6 weeks) IUD (within 48 hours or delay 4 weeks) Delay 6 weeks Progestogen-only oral contraceptives Progestogen-only injectables Implants Diaphragm Delay 6 months Combined oral contraceptives Combined injectables Fertility awareness methods
D28
D29
Delivery care
Follow the labour and delivery procedures . D2-D28 K11 Observe universal precautions . A4 Give Supportive care. Involve the companion in care and support . D6-D7 Maintain the partograph and labour record . N4-N6 Provide newborn care . J2-J8 Refer to facility as soon as possible if any abnormal mal finding in mother or baby B17 K14 B14
POSTPARTUM CARE
E2 POSTPARTUM EXAMINATION OF THE MOTHER (UP TO 6 WEEKS) E8 RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (6)
If vaginal discharge 4 weeks after delivery If breast problem
E3
E9
E4
E10
E5
Always begin with Rapid assessment and management (RAM) . B2-B7 Next use the Postpartum examination of the mother . E2
If an abnormal sign is identified (volunteered or observed), use the charts Respond to observed signs or volunteered problems . E3-E10 Record all treatment given, positive findings, and the scheduled next visit in the home-based and clinic recording form. For the first or second postpartum visit during the first week after delivery, use the Postpartum examination chart D21 and Advise counselling section D26 to examine and advise the mother. If the woman is HIV positive, adolescent or has special needs, use G1-G8 H1-H4
E7
Postpartum care
E1
Postpartum care
POSTPARTUM CARE
E2
CLASSIFY
NORMAL POSTPARTUM
CLASSIFY
HYPERTENSION BLOOD PRESSURE NORMAL
Respond to observed signs or volunteered problems (1) If elevated diastolic blood pressure
E3
Respond to observed signs or volunteered problems (2) If pallor, check for anaemia
POSTPARTUM CARE
E4
IF PALLOR, CHECK FOR ANAEMIA ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS
Check record for bleeding in pregnancy, delivery or postpartum. Have you had heavy bleeding since delivery? Do you tire easily? Are you breathless (short of breath) during routine housework? Measure haemoglobin if history of bleeding. Look for conjunctival pallor. Look for palmar pallor. If pallor: is it severe pallor? some pallor? Count number of breaths in 1 minute. Haemoglobin <7 g/dl AND/OR Severe palmar and conjunctival pallor or Any pallor and any of: >30 breaths per minute tires easily breathlessness at rest. Haemoglobin 7-11 g/dl OR Palmar or conjunctival pallor. Haemoglobin >11g/dl. No pallor.
CLASSIFY
SEVERE ANAEMIA
MODERATE ANAEMIA
Give double dose of iron for 3 months . F3 Reassess at next postnatal visit (in 4 weeks). If anaemia persists, refer to hospital. Continue treatment with iron for 3 months altogether F3
NO ANAEMIA
SIGNS
Known HIV-positive.
CLASSIFY
HIV-POSITIVE
Not been tested, no HIV test results, or not willing to disclose result.
Known HIV-negative.
HIV-NEGATIVE
Respond to observed signs or volunteered problems (3) Check for HIV status
E5
E6
TREAT AND ADVISE
Give 0.2 mg ergometrine IM .B10 Give appropriate IM/IV antibiotics .B15 Manage as in Rapid assessment and management B15-B7 . Refer urgently to hospital .B17 Insert an IV line and give fluids rapidly . B9 Give appropriate IM/IV antibiotics B15 . Refer urgently to hospital .B17
SIGNS
More than 1 pad soaked in 5 minutes.
CLASSIFY
POSTPARTUM BLEEDING
Feel lower abdomen and flanks for tenderness. Look for abnormal lochia. Measure temperature. Look or feel for stiff neck. Look for lethargy.
Give appropriate IM/IV antibiotics .B15 Refer urgently to hospital .B17 Give appropriate oral antibiotic . F5 - Nitrofurantoin 100mg QID x 7days OR Ciprofloxacin 250mg BID x 3 days Encourage her to drink more fluids. Follow up in 2 days. If no improvement, refer to hospital. Insert an IV line . B9 Give appropriate IM/IV antibiotics .B15 Give artemether IM (or quinine IM if artemether not available) and glucose .B16 Refer urgently to hospital . B17 Give oral antimalarial . F4 Follow up in 2 days. If no improvement, refer to hospital.
Fever >38C.
MALARIA
CLASSIFY
URINARY INCONTINENCE
Remove sutures, if present. Clean wound. Counsel on care and hygiene . D26 Give paracetamol for pain F4 ,IM/IV antibiotical B15 Follow up in 2 days. If no improvement, refer to hospital Provide emotional support. Refer urgently the woman to hospital . B7
Assure the woman that this is very common. Listen to her concerns. Give emotional encouragement and support. Counsel partner and family to provide assistance to the woman. Follow up in 2 weeks, and refer if no improvement.
E7
E8
CLASSIFY TREAT AND ADVISE
Give appropriate IM oral antibiotics to woman . F5 Treat partner with appropriate IM oral antibiotics F5 Advise on correct and consistent use of condoms .G2 Give clotrimazole . F5 Advise on correct and consistent use of condoms F4 If no improvement, refer the woman to hospital.
SIGNS
IF BREAST PROBLEM
See J9J9
CLASSIFY
POSSIBLE PNEUMONIA
At least 1 of the following: POSSIBLE CHRONIC Cough or breathing difficulty for >3 LUNG DISEASE weeks. Blood in sputum. Wheezing. Temperature <38C. Cough for <3 weeks. UPPER RESPIRATORY TRACT INFECTION
Refer to hospital for assessment. If severe wheezing, refer urgently to hospital. Use Practical Approach to Lung health guidelines (PAL) for further management. Advise safe, soothing remedy. If smoking, counsel to stop smoking. Follow-up in 1 week. If no improvement refer to hospital for assesment
E9
Respond to observed signs or volunteered problems (8) If signs suggesting HIV infection
POSTPARTUM CARE
E10
SIGNS
CLASSIFY
Two of the following: STRONG weight loss LIKELIHOOD OF HIV fever >1 month INFECTION diarrhoea >1 month. OR One of the above signs and one or more other sign or from a high-risk group.
E9
This section has details on preventive measures and treatments prescribed in pregnancy and postpartum. General principles are found in the section on good practice . A2 For emergency treatment for the woman see .B8-B17
F3
K9-K13 K9-K13 .
F4
F5
F6
F1
F2
Give mebendazole
Give 500 mg to every woman once in 6 months. DO NOT give it in the first trimester. note: 2 tablets per day if prenatal consultations are done during the 2nd or 3rd trimester. Mebendazole 500 mg tablet 1 tablet 100 mg tablet 5 tablets
F3
Additional treatments for the woman (1) Antimalarial treatment and paracetamol
ANTIMALARIAL TREATMENT AND PARACETAMOL
PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN
F4
Give paracetamol
If severe pain Paracetamol 1 tablet = 500 mg Dose 1-2 tablets every Frequency 4-6 hours
ANTIBIOTIC
CLOXACILLIN 1 capsule (500 mg) AMOXYCILLIN 1 tablet (500 mg) OR TRIMETHOPRIM+ SULPHAMETHOXAZOLE (1 tablet-250 mg) OR NITROFURANTOIN OR CIPROFLAXCIN CEFTRIAXONE + (Vial=250 mg) AZITHROMYCIN CEPFRIAXONE OR CIPROFLOXACIN (1 tablet=250 mg) DOXYCYCLINE
DOSE
500 mg 500 mg 80 mg
FREQUENCY
every 6 hours every 8 hours two tablets every 12 hours
DURATION
10 days 3 days 3 days
COMMENT
Avoid in late pregnancy and two weeks after delivery when breastfeeding. Avoid in pregnancy
100 mg 250 mg 250 mg IM injection 1gm 250mg 500 mg (2 tablets) 100 mg once only once only once only once only 1 tablet every 12 hours once only every 12 hours every night once only
7 days 3 days once only once only Not safe for pregnant or lactating women. 7 days Avoid in pregnancy
Teach the woman how to insert a supposity into vagina before and after each application. (Caution to pregnant women: determine if benefit outweighs the risk)
Additional treatments for the woman (2) Give appropriate oral antibiotics
F5
F6
INDICATION
Syphilis RPR test positive
ANTIBIOTIC
BENZATHINE PENICILLIN IM (2.4 million units in 5 ml) ERYTHROMYCIN (1 tablet = 250 mg) TETRACYCLINE (1 tablet = 250 mg) OR DOXYCYCLINE (1 tablet = 100 mg)
DOSE
2.4 million units IM injection 500 mg (2 tablets) 500 mg (2 tablets) 100 mg
FREQUENCY
once only
DURATION
once only
COMMENT
Give as two IM injections at separate sites. Plan to treat newborn .K12 Counsel on correct and consistent use of condoms G2 .
SIGNS
Any of these signs: Tightness in the chest and throat. Feeling dizzy and confused. Swelling of the face, neck and tongue. Injection site swollen and red. Rash or hives. Difficult breathing or wheezing.
CLASSIFY
ALLERGY TO PENICILLIN
TREAT
Open the airway .B9 Insert IV line and give fluids .B9 Give 0.5 ml adrenaline 1:1000 in 10 ml saline solution IV slowly. Repeat in 5-15 minutes, if required. DO NOT leave the woman on her own. Refer urgently to hospital B17
Use this section when accurate information on HIV must be given to the woman and her family. Provide key information on HIV to all women and explain at the first antenatal care visit how HIV is tramsitted and the advantages of knowing the HIV status in pregnancy. G2 Explain about voluntary counselling and testing (VCT) services, theimplications of the test result and benefits of involving and testing the male partner(s). Discuss confidentiality of results. G3 If the woman is HIV-positive (and willing to disclose the results): provide additional care during pregnancy, childbirth and postpartum. G4 give any particular support that she may require. G5 If antiretroviral prophylactic treatment to prevent mother-tochild transmission is a policy, give treatment according to that policy. G6 If a trained counsellor on infant feeding is not available, advise the woman about the choices. G7 If the woman is HIV-positive, counsel her and support the infant feeding she has chosen replacement feeding or breastfeeding . G8 Counsel all women on correct and consistent use of condoms during and after pregnancy. G2
G5 SUPPORT TO THE
HIV-POSITIVE WOMAN
Provide emotional support to the woman How to provide support
G6 PREVENT MOTHER-T0-CHILD
TRANSMISSION OF HIV
Give antiretroviral drug to prevent MTCT Antiretroviral drugs for MTCT of HIV
G7 COUNSEL ON INFANT
FEEDING CHOICE
Explain the risks of HIV transmission through breastfeeding and not breastfeeding If a woman has unknown or negative HIV status If a woman knows and accepts that she is HIV-positive
G1
G2
PROVIDE KEY INFORMATION ON HIV What is HIV (human immunodeficiency virus) and how is HIV transmitted?
HIV is a virus that destroys parts of the bodys immune system. A person infected with HIV may not feel sick at first, but slowly the bodys immune system is destroyed. The person becomes ill and unable to fight infection. Once a person is infected with HIV, she or he can give the virus to others. HIV can be transmitted through: Exchange of HIV-infected body fluids such as semen, vaginal fluid or blood during unprotected sexual intercourse. HIV-infected blood transfusions or contaminated needles. Sharing of instruments and needles for drug abuse or tattoos. From an infected mother to her child (MTCT) during: pregnancy labour and delivery postpartum through breastfeeding. HIV cannot be transmitted through hugging or mosquito bites. A special blood test is done to find out if the person is infected with HIV.
VOLUNTARY COUNSELLING AND TESTING (VCT) Voluntary counselling and testing (VCT) services
Explain about VCT services: VCT is used to determine the HIV status of an individual. Testing is voluntary. The woman has a right to refuse. VCT provides an opportunity to learn and accept the HIV status in a confidential environment. VCT includes pre-test counselling, blood testing and post-test counselling. If VCT is available in your setting and you are trained to do VCT, use national HIV guidelines to provide: Pre-test counselling. Post-test counselling. Infant feeding counselling. If VCT is not available in your setting, inform the woman about: Where to go. How the test is performed. How confidentiality is maintained. When and how results are given. Costs involved. Address of VCT service in your area:
____________________________________________________________________ ____________________________________________________________________
G3
G4
CARE AND COUNSELLING ON FAMILY PLANNING FOR THE HIV-POSITIVE WOMAN Additional care for the HIV-positive woman
Determine how much the woman has told her partner, labour companion and family, then respect this confidentiality. Be sensitive to her special concerns and fears. Give psychosocial support . G6 Advise on the importance of good nutrition .C16 D26 Use universal precautions as for all women .A4 Advise her that she is more prone to infections and should seek medical help as soon as possible if she has: fever persistent diarrhoea cold and cough respiratory infections burning urination vaginal itching/foul-smelling discharge severe weight loss skin infectionsC2 foul-smelling lochia. DURING PREGNANCY: Revise the birth plan C2 C13 Advise her to deliver in a facility. Advise her to go to a facility as soon as her membranes rupture or labour starts. Counsel her on antiretroviral prophylactic treatment .G7 Discuss the infant feeding plan . G8-G9 Modify preventive treatment for malaria, according to national strategy .F4 Use universal precautions as for all women . A4 DURING THE POSTPARTUM PERIOD: Tell her that lochia can cause infection in other people and therefore she should dispose of blood stained sanitary pads safely (list local options). If not breastfeeding exclusively, advise her to use a family planning method immediately .D27 If not breastfeeding, advise her on breast care . K8
G5
See also
F5
G6
PREVENT MOTHER-TO-CHILD TRANSMISSION (MTCT) OF HIV Give antiretroviral (ARV) drug to prevent mother-to-child transmission (MTCT) of HIV
Explain to the pregnant woman that the drug has been shown to greatly reduce the risk of infection of the baby. Explain to her that to receive ARV prophylactic treatment, she must: attend antenatal care regularly know her HIV status be counselled on infant feeding deliver with a skilled attendant preferably in a hospital be able and willing to take drugs as prescribed. If treatment with zidovudine (ZDV, AZT) is planned: obtain a haemoglobin determination early; if less than 8 g/dl, treat anaemia urgently and remeasure to assure adequate level for treatment. determine when woman will be at 36 weeks gestation and explain to her when to start treatment. Supply her with enough tablets for the beginning of labour, in case of any delay in reaching the hospital or clinic.
Antiretroviral drugs for prevention of MTCT of HIV (give according to national policy)
Zidovudine 1 tablet = 300 mg OR Nevirapine 1 tablet = 200 mg (woman) Oral solution 50 mg/5 ml (baby) When to give Dose Frequency From 36 weeks of pregnancy till onset of labour 300 mg (1 tablet) every 12 hours From onset of labour to delivery 300 mg (1 tablet) every 3 hours For woman: as early as possible in labour For newborn: Give within 72 hours of birth (before discharge from facility) 200 mg (1 tablet) once only 2 mg/kg once only (2 kg baby: 0.4 ml) (3 kg baby: 0.6 ml) Comment No treatment for the baby. If she vomits within first hour, repeat dose If mother received nevirapine less than 1 hour before delivery, give the treatment to the newborn soon after birth.
G7
COUNSEL ON INFANT FEEDING CHOICE
Special training is required to counsel an HIV-positive mother about infant feeding choices and to support her chosen method. This guide does not substitute for special training. HIV-positive women should be referred to a health worker trained in infant-feeding counselling. However, if a trained counsellor is not available, or the woman will not seek the help of a trained counsellor, counsel her as follows.
Explain the risks of HIV transmission through breastfeeding and not breastfeeding
Five out of 20 babies born to known HIV-positive mothers will be infected during pregnancy and delivery without ARV medication. Three more may be infected by breastfeeding. The risk may be reduced if the baby is breastfed exclusively using good technique, so that the breasts stay healthy. Mastitis and nipple fissures increase the risk that the baby will be infected. The risk of not breastfeeding may be much higher because replacement feeding carries risks too: diarrhoea because of contamination from unclean water, unclean utensils or because the milk is left out too long. malnutrition because of insufficient quantity given to the baby, the milk is too watery, or because of recurrent episodes of diarrhoea. Mixed feeding may also increase the risk of HIV transmission and diarrhoea.
G7
G8
IF THE MOTHER CHOOSES REPLACEMENT FEEDING Teach the mother replacement feeding
Ask the mother what kind of replacement feeding she chose. For the first few feeds after delivery, prepare the formula for the mother, then teach her how to prepare the formula and feed the baby by cup: Wash hands with water and soap Boil the water for few minutes Clean the cup thoroughly with water, soap and, if possible, boil or pour boiled water in it Decide how much milk the baby needs from the instructions Measure the milk and water and mix them Teach the mother how to feed the baby by cup K9 Let the mother feed the baby 8 times a day (in the first month). Teach her to be flexible and respond to the babys demands If the baby does not finish the feed within 1 hour of preparation, give it to an older child or add to cooking. DO NOT give the milk to the baby for the next feed Wash the utensils with water and soap soon after feeding the baby Make a new feed every time. Give her written instructions on safe preparation of formula. Explain the risks of replacement feeding and how to avoid them. Advise when to seek care. Advise about the follow-up visit.
Give special counselling to the mother who is HIV-positive and chooses breastfeeding
Support the mother in her choice of breastfeeding. Ensure good attachment and suckling to prevent mastitis and nipple damage . K3 Advise the mother to return immediately if: she has any breast symptoms or signs the baby has any difficulty feeding. Ensure a visit in the first week to assess attachment and positioning and the condition of the mothers breasts. Arrange for further counselling to prepare for the possibility of stopping breastfeeding early. Give psychosocial support . G6
K3
If a woman is an adolescent or living with violence, she needs special consideration. During interaction with such women, use this section to support them.
H3
H4
H1
H2
Sources of support
A key role of the health worker includes linking the health services with the community and other support services available. Maintain existing links and, when possible, explore needs and alternatives for support through the following: Community groups, womens groups, leaders. Peer support groups. Other health service providers. Community counsellors. Traditional providers.
Emotional support
Principles of good care, including suggestions on communication with the woman and her family, are provided on. A2 When giving emotional support to the woman with special needs it is particularly important to remember the following: Create a comfortable environment: Be aware of your attitude Be open and approachable Use a gentle, reassuring tone of voice. Guarantee confidentiality and privacy: Communicate clearly about confidentiality. Tell the woman that you will not tell anyone else about the visit, discussion or plan. If brought by a partner, parent or other family member, make sure you have time and space to talk privately. Ask the woman if she would like to include her family members in the examination and discussion. Make sure you seek her consent first. Make sure the physical area allows privacy. Convey respect: Do not be judgmental Be understanding of her situation Overcome your own discomfort with her situation. Give simple, direct answers in clear language: Verify that she understands the most important points. Provide information according to her situation which she can use to make decisions. Be a good listener: Be patient. Women with special needs may need time to tell you their problem or make a decision Pay attention to her as she speaks. Follow-up visits may be necessary.
Help the girl consider her options and to make decisions which best suit her needs.
Birth planning: delivery in a hospital or health centre is highly recommended. She needs to understand why this is important, she needs to decide if she will do it and and how she will arrange it. Prevention of STI or HIV/AIDS is important for her and her baby. If she or her partner are at risk of STI or HIV/AIDS, they should use a condom in all sexual relations. She may need advice on how to discuss condom use with her partner. Spacing of the next pregnancy for both the woman and babys health, it is recommended that any next pregnancy be spaced by at least 2 or 3 years. The girl, with her partner if applicable, needs to decide if and when a second pregnancy is desired, based on their plans. Healthy adolescents can safely use any contraceptive method. The girl needs support in knowing her options and in deciding which is best for her. Be active in providing family planning counselling and advice.
H3
H4
Support the health service response to needs of women living with violence
Help raise awareness among health care staff about violence against women and its prevalence in the community the clinic serves. Find out what if training is available to improve the support that health care staff can provide to those women who may need it. Display posters, leaflets and other information that condemn violence, and information on groups that can provide support. Make contact with organizations working to address violence in your area. Identify those that can provide support for women in abusive relationships. If specific services are not available, contact other groups such as churches, womens groups, elders, or other local groups and discuss with them support they can provide or other what roles they can play, like resolving disputes. Ensure you have a list of these resources available.
Everyone in the community should be informed and involved in the process of improving the health of their community members. This section provides guidance on how their involvement can help improve the health of women and newborns. Different groups should be asked to give feedback and suggestions on how to improve the services the health facilities provide. Use the following suggestions when working with families and communities to support the care of women and newborns during pregnancy, delivery, post-abortion and postpartum periods.
l3
I1
Establish links
COMMUNITY SUPPORT FOR MATERNAL AND NEWBORN HEALTH
I2
ESTABLISH LINKS Coordinate with other health care providers and community groups
Meet with others in the community to discuss and agree messages related to pregnancy, delivery, postpartum and post-abortion care of women and newborns. Work together with leaders and community groups to discuss the most common health problems and find solutions. Groups to contact and establish relations which include: other health care providers traditional birth attendants and healers maternity waiting homes adolescent health services schools nongovernmental organizations breastfeeding support groups district health committees womens groups agricultural associations neighbourhood committees youth groups church groups. Establish links with peer support groups and referral sites for women with special needs, including women living with HIV, adolescents and women living with violence. Have available the names and contact information for these groups and referral sites, and encourage the woman to seek their support.
I3
NEWBORN CARE
J2 EXAMINE THE NEWBORN J8 IF SWELLING, BRUISES OR MALFORMATION Examinine routinely all babies around an hour of birth, for discharge, at routine and follow-up postnatal visits in the first weeks of life, and when the provider or mother observes danger signs. Use the chart Assess the mothers breasts if the mother is complaining of nipple or breast pain . J9 During the stay at the facility, use the Care of the newborn chart J10 . If the baby is small but does not need referral, also use the Additional care for a small baby or twin chart . J11 Use the Breastfeeding, care, preventive measures and treatment for the newborn sections for details of care, resuscitation and treatments .K1-K13 Use Advise on when to return with the baby K14 for advising the mother when to return with the baby for routine and follow-up visits and to seek care or return if baby has danger signs. Use information and counselling sheets . M5-M6 For care at birth and during the first hours of life, use Labour and delivery . D19 ALSO SEE: Counsel on choices of infant feeding and HIV-related issues . Equipment, supplies and drugs . L1-L5 Records . N1-N7 J6 LOOK FOR SIGNS OF JAUNDICE AND LOCAL INFECTION J12 NEWBORN SCREENING Baby died D24 K14
J9
J4 ASSESS BREASTFEEDING
J10
J5
J11
G7-G8
J7
IF DANGER SIGNS
Newborn care
J1
J2
CLASSIFY
Normal weight baby WELL BABY (2500g or more). Feeding well suckling effectively 8 times in 24 hours, day and night. No danger signs. No special treatment needs or treatment completed. Small baby, feeding well and gaining weight adequately.
Body temperature 35-36.4C. Mother not able to breastfeed due to receiving special treatment. Mother transferred.
HYPOTHERMIA
SIGNS
Birth weight <1500 g. Very preterm <32 weeks or >2 months early). Birth weight 1500g-<2500g. Preterm baby (32-36 weeks or 1-2 months early). Several days old and weight gain inadequate. Feeding difficulty.
CLASSIFY
VERY SMALL BABY
SMALL BABY
Twin
TWIN
J3
Assess breastfeeding
NEWBORN CARE
J4
ASSESS BREASTFEEDING
Assess breastfeeding in every baby as part of the examination. If mother is complaining of nipple or breast pain, also assess the mothers breasts J9
CLASSIFY
FEEDING WELL
Not yet breastfed (first hours of life). FEEDING DIFFICULTY Not well attached. Not suckling effectively. Breastfeeding less than 8 times per 24 hours. Receiving other foods or drinks. Several days old and inadequate weight gain. Not suckling (after 6 hours of age). NOT ABLE TO FEED Stopped feeding.
Support exclusive breastfeeding . K2-K3 Help the mother to initiate breastfeeding K3 Teach correct positioning and attachment . K3 Advise to feed more frequently, day and night. Reassure her that she has enough milk. Advise the mother to stop feeding the baby other foods or drinks. Reassess at the next feed or follow-up visit in 2 days. Refer baby urgently to hospital K14
CLASSIFY
RISK OF BACTERIAL INFECTION
Give baby single dose of benzathine penicillin K12 . Ensure mother and partner are treated . F6 Follow up in 2 weeks. Give special counselling to mother who is breastfeeding . G8 Refer for counselling on infant feeding . G7 Follow up in 2 weeks. Give baby isoniazid prophylaxis for 6 months. K13 Give BCG vaccination to the baby only when babys treatment completed. Follow up in 2 weeks.
RISK OF TUBERCULOSIS
J5
J6
SIGNS
Yellow skin on face and only <24 hours old. Yellow palms and soles and !!!!" 24 hours old.
Red umbilicus or skin around it. LOCAL UMBILICAL INFECTION Less than 10 pustules LOCAL SKIN INFECTION
IF DANGER SIGNS
SIGNS
Any of the following signs: Fast breathing (more than 60 breaths per minute). Slow breathing (less than 30 breaths per minute). Severe chest in-drawing Grunting Convulsions. Floppy or stiff. Fever (temperature >38C). Temperature <35C or not rising after rewarming. Umbilicus draining pus or umbilical redness extending to skin. More than 10 skin pustules or bullae, or swelling, redness, hardness of skin. Bleeding from stump or cut. Pallor. Cyanosis of lips and mucous membranes. Apnea (not breathing)
CLASSIFY
POSSIBLE SERIOUS ILLNESS
In addition: Re-warm and keep warm during referral . K9 Treat local umbilical infection before referral . K13 Treat skin infection before referral . K13 Stop the bleeding. Give oxygen if available. Start newborn resuscitation. Refer to the hospital. B17
If danger signs
J7
J8
SIGNS
Bruises, swelling on buttocks. Swollen head bump on one or both sides. Abnormal position of legs (after breech presentation). Asymmetrical arm movement, arm does not move. Club foot Cleft palate or lip
CLASSIFY
BIRTH INJURY
MALFORMATION
Refer for special treatment if available. Help mother to breastfeed. If not successful, teach her alternative feeding methods . K5-K6 Plan to follow up. Advise on surgical correction at age of several months. Refer for special evaluation. Cover with sterile tissues soaked with sterile saline solution before referral. Refer for special treatment if available.
Odd looking, unusual appearance Open tissue on head, abdomen or back Non-passage of meconium on first 24 hrs Other abnormal appearance. SEVERE MALFORMATION
SIGNS
No swelling, redness or tenderness. BREASTS Normal body temperature. HEALTHY Nipple not sore and no fissure visible. Baby well attached. Nipple sore or fissured. Baby not well attached. NIPPLE SORENESS OR FISSURE
Encourage the mother to continue breastfeeding. Teach correct positioning and attachment . K3 Reassess after 2 feeds (or 1 day). If not better, teach the mother how to express breast milk from the affected breast and feed baby by cup, and continue breastfeeding on the healthy side. Encourage the mother to continue breastfeeding. Teach correct positioning and attachment . K3 Advise to feed more frequently. Reassess after 2 feeds (1 day). If not better, teach mother how to express enough breast milk before the feed to relieve discomfort . K5 Encourage mother to continue breastfeeding. Teach correct positioning and attachment . K3 Give cloxacillin for 10 days .F5 Reassess in 2 days. If no improvement or worse, refer to hospital. If mother is HIV+ let her breastfeed on the healthy breast. Express milk from the affected breast and discard until no fever . K5 If severe pain, give paracetamol F4
Both breasts are swollen, shiny and patchy red. Temperature <38C. Baby not well attached. Not yet breastfeeding. Part of breast is painful, swollen and red. Temperature >38C Feels ill.
BREAST ENGORGEMENT
MASTITIS
J9
J10
If mother reports breastfeeding difficulty, assess breastfeeding and help the mother with positioning and attachment J3
If the mother is unable to take care of the baby, provide care or teach the companion K9-K10 Wash hands before and after handling the baby.
If feet are cold: each the mother to put the baby skin-to-skin . K13 Reassess in 1 hour; if feet still cold, measure temperature and re-warm the baby K9 . If bleeding from cord, check if tie is loose and retie the cord. If other bleeding, assess the baby immediately .J2-J7 If breathing difficulty or mother reports any other abnormality, examine the baby as on . J2-J7 J2-J7
K9 K13 J3
Give prescribed treatments according to the schedule . K12 Examine every baby before planning to discharge mother and baby . J2-J9 DO NOT discharge before baby is 12 hours old.
If the small baby is not suckling effectively and does not have other danger signs, consider alternative feeding methods .K5-K6 Teach the mother how to hand express breast milk directly into the babys mouth K5 Teach the mother to express breast milk and cup feed the baby K5-K6 Determine appropriate amount for daily feeds by age . K6 If feeding difficulty persists for 3 days, or weight loss greater than 10% of birth weight and no other problems, refer for breastfeeding counselling and management.
If difficult to keep body temperature within the normal range (36.5C to 37.5C): Keep the baby in skin-to-skin contact with the mother as much as possible If body temperature below 36.5C persists for 2 hours despite skin-to-skin contact with mother,assess the baby .J2-J8 If breathing difficulty, assess the baby . J2-J8 If jaundice, refer the baby for phototherapy. If any maternal concern, assess the baby and respond to the mother . J2-J8 If the mother and baby are not able to stay, ensure daily (home) visits or send to hospital.
Plan to discharge when: Breastfeeding well Gaining weight adequately on 3 consecutive days Body temperature between 36.5 and 37.5C on 3 consecutive days Mother able and confident in caring for the baby No maternal concerns. Assess the baby for discharge.
J11
J12
J12
J2
K14 ADVISE WHEN TO RETURN
Routine visits Follow-up visits Advise the mother to seek care for the baby Refer baby urgently to hospital
This section has details on breastfeeding, care of the baby, treatments, immunization, routine and follow-up visits and urgent referral to hospital. General principles are found in the section on good care A1-A6 If mother HIV-positive, see also G7-G8
K5 ALTERNATIVE
Keep the baby warm Open the airway If still not breathing, ventilate... If breathing or crying, stop ventilating If not breathing or gasping at all after 20 minutes of ventilation
K6 ALTERNATIVE
K1
K2
COUNSEL ON BREASTFEEDING Counsel on importance of exclusive breastfeeding during pregnancy and after birth
INCLUDE PARTNER OR OTHER FAMILY MEMBERS IF POSSIBLE Explain to the mother that: Breast milk contains exactly the nutrients a baby needs is easily digested and efficiently used by the babys body protects a baby against infection. Babies should start breastfeeding within 1 hour of birth. They should not have any other food or drink before they start to breastfeed. Babies should be exclusively breastfed for the first 6 months of life. Breastfeeding helps babys development and mother/baby attachment can help delay a new pregnancy (see D27 for breastfeeding and family planning). For counselling if mother HIV-positive, see G7 G7
Help the mother to initiate breastfeeding within 1 hour, when baby is ready
After birth, let the baby rest comfortably on the mothers chest in skin-to-skin contact. Tell the mother to help the baby to her breast when the baby seems to be ready, usually within the first hour. Signs of readiness to breastfeed are: baby looking around/moving mouth open searching. Check that position and attachment are correct at the first feed. Offer to help the mother at any time. K3 Let the baby release the breast by her/himself; then offer the second breast. If the baby does not feed in 1 hour, examine the babyn J2-J9 . If healthy, leave the baby with the mother to try later. Assess in 3 hours, or earlier if the baby is small . J4 If the mother is ill and unable to breastfeed, help her to express breast milk and feed the baby by cup K6 . On day 1 express in a spoon and feed by spoon. If mother cannot breastfeed at all, use one of the following options: home-made or commercial formula donated heat-treated breast milk.
Assess breastfeeding
Support exclusive breastfeeding
Keep the mother and baby together in bed or within easy reach. DO NOT separate them. Encourage breastfeeding on demand, day and night, as long as the baby wants. A baby needs to feed day and night, 8 or more times in 24 hours from birth. Only on the first day may a full-term baby sleep many hours after a good feed. A small baby should be encouraged to feed, day and night, at least 8 times in 24 hours from birth. Help the mother whenever she wants, and especially if she is a first time or adolescent mother. Let baby release the breast, then offer the second breast. If mother must be absent, let her express breast milk and let somebody else feed the expressed breast milk to the baby by cup. DO NOT force the baby to take the breast. DO NOT interrupt feed before baby wants. DO NOT give any other feeds or water. DO NOT use artificial teats or pacifiers. Advise the mother on medication and breastfeeding Most drugs given to the mother in this guide are safe and the baby can be breastfed. If mother is taking cotrimoxazole or fansidar, monitor baby for jaundice.
J4
Teach correct positioning and attachment for breastfeeding
Show the mother how to hold her baby. She should: make sure the babys head and body are in a straight line make sure the baby is facing the breast, the babys nose is opposite her nipple hold the babys body close to her body support the babys whole body, not just the neck and shoulders Show the mother how to help her baby to attach. She should: touch her babys lips with her nipple wait until her babys mouth is opened wide move her baby quickly onto her breast, aiming the infants lower lip well below the nipple. Look for signs of good attachment and effective suckling (that is, slow, deep sucks, sometimes pausing). If the attachment or suckling is not good, try again. Then reassess. If breast engorgement, express a small amount of breast milk before starting breastfeeding to soften nipple area so that it is easier for the baby to attach. If mother is HIV-positive, see G7 for special counselling to the mother who is HIV-positive and breastfeeding. If mother chose replacement feedings, see G8 . G8
G7
K3
K4
COUNSEL ON BREASTFEEDING Give special support to breastfeed the small baby (preterm and/or low birth weight)
COUNSEL THE MOTHER: Reassure the mother that she can breastfeed her small baby and she has enough milk. Explain that her milk is the best food for such a small baby. Feeding for her/him is even more important than for a big baby. Explain how the milks appearance changes: milk in the first days is thick and yellow, then it becomes thinner and whiter. Both are good for the baby. A small baby does not feed as well as a big baby in the first days: may tire easily and suck weakly at first may suckle for shorter periods before resting may fall asleep during feeding may have long pauses between suckling and may feed longer does not always wake up for feeds. Explain that breastfeeding will become easier if the baby suckles and stimulates the breast her/himself and when the baby becomes bigger. Encourage skin-to-skin contact since it makes breastfeeding easier. HELP THE MOTHER: Initiate breastfeeding within 1 hour of birth. Feed the baby every 2-3 hours.Wake the baby for feeding, even if she/he does not wake up alone, 2 hours after the last feed. Always start the feed with breastfeeding before offering a cup. If necessary, improve the milk flow (let the mother express a little breast milk before attaching the baby to the breast). Keep the baby longer at the breast. Allow long pauses or long, slow feed. Do not interrupt feed if the baby is still trying. If the baby is not yet suckling well and long enough, do whatever works better in your setting: Let the mother express breast milk into babys mouth .K5 Let the mother express breast milk and feed baby by cup K6 . On the first day express breast milk into, and feed colostrum by spoon. Teach the mother to observe swallowing if giving expressed breast milk. Weigh the baby daily (if accurate and precise scales available), record and assess weight gain K7
J6
ALTERNATIVE FEEDING METHODS Express breast milk
The mother needs clean containers to collect and store the milk. A wide necked jug, jar, bowl or cup can be used. Once expressed, the milk should be stored with a well-fitting lid or cover. Teach the mother to express breast milk: To provide milk for the baby when she is away. To feed the baby if the baby is small and too weak to suckle To relieve engorgement and to help baby to attach To drain the breast when she has severe mastitis or abscesses. Teach the mother to express her milk by herself. DO NOT do it for her. Teach her how to: Wash her hands thoroughly. Sit or stand comfortably and hold a clean container underneath her breast. Put her first finger and thumb on either side of the areola, behind the nipple. Press slightly inwards towards the breast between her finger and thumb. Express one side until the milk flow slows. Then express the other side. Continue alternating sides for at least 20-30 minutes. If milk does not flow well: Apply warm compresses. Have someone massage her back and neck before expressing. Teach the mother breast and nipple massage. Feed the baby by cup immediately. If not, store expressed milk in a cool, clean and safe place. If necessary, repeat the procedure to express breast milk at least 8 times in 24 hours. Express as much as the baby would take or more, every 3 hours. When not breastfeeding at all, express just a little to relieve pain . K5 If mother is very ill, help her to express or do it for her.
K5
K6
If weighing daily with a precise and accurate scale First week No weight loss or total less than 10% Afterward daily gain in small babies at least 20 g
Scale maintenance
Daily/weekly weighing requires precise and accurate scale (10 g increment): Calibrate it daily according to instructions. Check it for accuracy according to instructions. Simple spring scales are not precise enough for daily/weekly weighing.
K7
K8
OTHER BREASTFEEDING SUPPORT Give special support to the mother who is not yet breastfeeding
(Mother or baby ill, or baby too small to suckle) Teach the mother to express breast milk K5 . Help her if necessary. Use the milk to feed the baby by cup. If mother and baby are separated, help the mother to see the baby or inform her about the babys condition at least twice daily. If the baby was referred to another institution, ensure the baby gets the mothers expressed breast milk if possible. Encourage the mother to breastfeed when she or the baby recovers.
Advise the mother who is not breastfeeding at all on how to relieve engorgement
(Baby died or stillborn, mother chose replacement feeding) Breasts may be uncomfortable for a while. Avoid stimulating the breasts. Support breasts with a well-fitting bra or cloth. Do not bind the breasts tightly as this may increase her discomfort. Apply a compress.Warmth is comfortable for some mothers, others prefer a cold compress to reduce swelling. Teach the mother to express enough milk to relieve discomfort. Expressing can be done a few times a day when the breasts are overfull. It does not need to be done if the mother is uncomfortable. It will be less than her baby would take and will not stimulate increased milk production. Relieve pain. An analgesic such as ibuprofen, or paracetamol may be used. Some women use plant products such as teas made from herbs, or plants such as raw cabbage leaves placed directly on the breast to reduce pain and swelling. Advise to seek care if breasts become painful, swollen, red, if she feels ill or temperature greater than 38C. Pharmacological treatments to reduce milk supply are not recommended. The above methods are considered more effective in the long term.
K9
K10
Cord care
Wash hands before and after cord care. Put nothing on the stump. Fold nappy (diaper) below stump. Keep cord stump loosely covered with clean clothes. If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth. If umbilicus is red or draining pus or blood, examine the baby and manage accordingly . J2-J7 Explain to the mother that she should seek care if the umbilicus is red or draining pus or blood. DO NOT bandage the stump or abdomen. DO NOT apply any substances or medicine to stump. Avoid touching the stump unnecessarily.
D19
Sleeping
Use the bednet day and night for a sleeping baby. Let the baby sleep on her/his back or on the side. Keep the baby away from smoke or people smoking. Keep the baby, especially a small baby, away from sick children or adults.
NEWBORN RESUSCITATION
Start resuscitation within 1 minute of birth if baby is not breathing or is gasping for breath. A4 Observe universal precautions to prevent infection A4 .
Use this guideline: -If only a single health provider is available -If a team of skilled health attendants are available, follow guidelines recommended for newborn resuscitation by the American Academy of Pediatrics
Newborn resuscitation
K11
K12
Weight 1.0 - 1.4 1.5 - 1.9 2.0 - 2.4 2.5 - 2.9 3.0 - 3.4 3.5 - 3.9 4.0 - 4.4
kg kg kg kg kg kg kg
Weight
1.0 1.4 kg 1.5 1.9 kg 2.0 2.4 kg 2.5 2.9 kg 3.0 3.4 kg 3.5 3.9 kg 4.0 4.4 kg
kg kg kg kg kg kg kg
the baby
Do the following 3 times daily: Wash hands with clean water and soap. Gently wash off pus and crusts with boiled and cooled water and soap. Dry the area with clean cloth. Paint with gentian violet. Wash hands.
REASSESS IN 2 DAYS:
Assess the skin, umbilicus or eyes. If pus or redness remains or is worse, refer to hospital. If pus and redness have improved, tell the mother to continue treating local infection at home.
K13
K14
Routine visits
Postnatal visit Immunization visit (If BCG and HB-1 given in the first week of life) Newborn screening Return Within the first week, preferably within 2-3 days At age 6 weeks On the 2nd day after birth and within 10 days
Follow-up visits
If the problem was: Feeding difficulty Red umbilicus Skin infection Eye infection Thrush Mother has either: breast engorgement or mastitis. Low birth weight, and either first week of life or not adequately gaining weight Low birth weight, and either older than 1 week or gaining weight adequately Orphan baby INH prophylaxis Treated for possible congenital syphilis Mother HIV-positive Return in 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 7 days 7 days 14 days 14 days 14 days 14 days
DURING TRANSPORTATION
Keep the baby warm by skin-to-skin contact with mother or someone else. Cover the baby with a blanket and cover her/his head with a cap. Protect the baby from direct sunshine. Encourage breastfeeding during the journey. If the baby does not breastfeed and journey is more than 3 hours, consider giving expressed breast milk by cup K6
J2
L3
L4
L5
L1
Equipment, supplies, drugs and tests for pregnancy and postpartum care
EQUIPMENT, SUPPLIES, DRUGS AND LABORATORY TESTS
L2
EQUIPMENT, SUPPLIES, DRUGS AND TESTS FOR ROUTINE AND EMERGENCY PREGNANCY AND POSTPARTUM CARE
Equipment
Baby scale Blood pressure machine and stethoscope Body thermometer Fetal stethoscope
Drugs
Adrenaline Amoxycillin Ampicillin Arthemether or quinine Azithromycin Benzathine penicillin Calcium gluconate Ceftriaxone Chloroquine tablet Ciprofloxacin Clotrimazole vaginal pessary Cloxacillin Criprofloxacin Diazepam Ergometrine Erythromycin Gentamicin Gentian violet Glucose 50% solution Hydralazine Iron/folic acid tablet Lignocaine Magnesium sulphate Mebendazole Metronidazole Nevirapine or zidovudine Nitrofurantoin Normal saline 0.9% Oxytocin Paracetamol Ringer lactate Sulphadoxine-pyrimethamine Tetracycline or doxycycline Trimethoprim + sulfamethoxazole Water for injection
Vaccine
Tetanus toxoid
Hand washing
Clean water supply Soap Nail brush or stick Clean towels
Supplies
Antiseptic solution (iodophors or chlorhexidine) Bleach (chlorine base compound) Condoms Gloves: utility sterile or highly disinfected long sterile for manual removal of placenta Impregnated bednet IV tubing Spirit (70% alcohol) Suture material for tear or episiotomy repair Swabs Syringes and needles Urinary catheter
Waste
Bucket for soiled pads and swabs Receptacle for soiled linens Container for sharps disposal
Sterilization
Instrument sterilizer Jar for forceps
Miscellaneous
Wall clock Torch with extra batteries and bulb Log book Records Refrigerator
Tests
Container for catching urine Proteinuria sticks RPR testing kit
EQUIPMENT, SUPPLIES AND DRUGS FOR CHILDBIRTH CARE Equipment Warm and clean room Supplies for Newborn Baby scale Delivery bed: a bed that supports the woman in a semi-sitting or Screening Blood pressure machine and stethoscope lying in a lateral position, with removable stirrups (only for repairing
the perineum or instrumental delivery) Clean bed linen Curtains if more than one bed Clean surface (for alternative delivery position) Work surface for resuscitation of newborn near delivery beds Light source Heat source Room thermometer Body thermometer Fetal stethoscope Mucus extractor with suction tube Self inflating bag and mask - neonatal size Alcohol or sterile water Clean gloves Dry and wet cotton balls/swabs Drying rack Tape Newborn screening filter card (properly filled-up) Sterile lancets (3mm) Warm, moist towel
J4
Vaccine
BCG OPV Hepatitis B
Contraceptives
Spacing Method IUD Pills Injectables/DMPA Condoms NFP BBT Cervical mucus Symptothermal LAM Permanent Method Bilateral tubal ligation Vasectomy for Male
Hand washing
Clean water supply Soap Nail brush or stick Clean towels
Drugs
Adrenaline Ampicillin Aquamephyton 10mg/ml (0.1ml IM) Benzathine penicillin Calcium gluconate Diazepam Ergometrine Eye antimicrobial (1% silver nitrate or 2.5% povidone iodine) Gentamicin Hydralazine Izoniazid Lignocaine Magnesium sulphate Metronidazole Nevirapine or zidovudine Normal saline 0.9% Oxytocin Ringer lactate Tetracycline 1% eye ointment Vitamin A Water for injection
Supplies
Antiseptic solution (iodophors or chlorhexidine) Baby feeding cup Blanket for the baby Bleach (chlorine-base compound) Clean (plastic) sheet to place under mother Clean towels for drying and wrapping the baby Cord ties (sterile) Gloves: utility sterile or highly disinfected long sterile for manual removal of placenta Long plastic apron Impregnated bednet IV tubing Sanitary pads Spirit (70% alcohol) Suture material for tear or episiotomy repair Swabs Syringes and needles Urinary catheter
Waste
Container for sharps disposal Receptacle for soiled linens Bucket for soiled pads and swabs Bowl and plastic bag for placenta
Sterilization
Instrument sterilizer Jar for forceps
Miscellaneous
Wall clock Torch with extra batteries and bulb Log book Records Refrigerator
L3
L4
LABORATORY TESTS
Check haemoglobin
Draw blood with syringe and needle or a sterile lancet. Insert below instructions for method used locally.
DIPSTICK METHOD
Dip coated end of paper dipstick in urine sample. Shake off excess by tapping against side of container. Wait specified time (see dipstick instructions). Compare with colour chart on label. Colours range from yellow (negative) through yellow-green and green-blue for positive.
BOILING METHOD
Put urine in test tube and boil top half. Boiled part may become cloudy. After boiling allow the test tube to stand. A thick precipitate at the bottom of the tube indicates protein. Add 2-3 drops of 2-3% acetic acid after boiling the urine (even if urine is not cloudy) If the urine remains cloudy, protein is present in the urine. If cloudy urine becomes clear, protein is not present. If boiled urine was not cloudy to begin with, but becomes cloudy when acetic acid is added, protein is present.
J5
J6
Interpreting results
After 8 minutes rotation, inspect the card in good light. Turn or tilt the card to see whether there is clumping (reactive result). Most test cards include negative and positive control circles for comparison. 1. Non-reactive (no clumping or only slight roughness) Negative for syphilis 2. Reactive (highly visible clumping) Positive for syphilis 3. Weakly reactive (minimal clumping) Positive for syphilis
NOTE: Weakly reactive can also be more finely granulated and difficult to see than in this illustration.
* Make sure antigen was refrigerated (not frozen) and has not expired. ** Room temperature should be 73-85F (22.829.3C).
Laboratory tests (2) Perform rapid plasmareagin (RPR) test for syphilis
L5
J2
M8 CLEAN HOME DELIVERY (1)
Delivery at home with an attendant Instructions to mother and family for a clean and safer delivery at home
These individual sheets have key information for the mother, her partner and family on care during pregnancy, preparing a birth and emergency plan, clean home delivery, care for the mother and baby after delivery, breastfeeding and care after an abortion. Individual sheets are used so that the woman can be given the relevant sheet at the appropriate stage of pregnancy and childbirth.
M9
M7 BREASTFEEDING
Breastfeeding has many advantages for the baby and the mother Suggestions for successful breastfeeding Health worker support Breastfeeding and family planning
M1
M2
J4
Preparing an emergency plan
To plan for an emergency, consider: Where should you go? How will you get there? Will you have to pay for transport to get there? How much will it cost? What costs will you have to pay at the health centre? How will you pay for this? Can you start saving for these possible costs now? Who will go with you to the health centre? Who will help to care for your home and other children while you are away?
M3
M4
___________________________________________________________________ ____________________________________________________________________
Family planning
You can become pregnant within several weeks after delivery if you have sexual relations and is not breastfeeding exclusively. Talk to the health worker about choosing a family planning method which best meets your and your partners needs.
J6
Know these danger signs
If you have any of these signs, go to the health centre immediately, day or night. DO NOT wait: Increased bleeding or continued bleeding for 2 days. Fever, feeling ill. Dizziness or fainting. Abdominal pain. Backache. Nausea, vomiting. Foul-smelling vaginal discharge.
Family planning
INFORMATIONAND AND COUNSELLING SHEETS INFORMATION COUNSELLING SHEETS
Remember you can become pregnant as soon as you have sexual relations. Use a family planning method to prevent an unwanted pregnancy. Talk to the health worker about choosing a family planning method which best meets your and your partners needs.
Additional support
The health worker can help you identify persons or groups who can provide you with additional support if you should need it.
M5
M6
At 6 weeks :
At these visits your baby will be vaccinated. Have your baby immunized.
OTHER ADVICE
Let the baby sleep on her/his back or side. Keep the baby away from smoke.
The health worker can support you in starting and maintaining breastfeeding
The health worker can help you to correctly position the baby and ensure she/he attaches to the breast. This will reduce breast problems for the mother. The health worker can show you how to express milk from your breast with your hands. If you should need to leave the baby with another caretaker for short periods, you can leave your milk and it can be given to the baby in a cup. The health worker can put you in contact with a breastfeeding support group. If you have any difficulties with breastfeeding, see the health worker immediately.
Breastfeeding
M7
M8
Instructions to mother and family for a clean and safer delivery at home
Make sure there is a clean delivery surface for the birth of the baby. Ask the attendant to wash her hands before touching you or the baby. The nails of the attendant should be short and clean. When the baby is born, place her/him on your abdomen/chest where it is warm and clean. Dry the baby thoroughly and wipe the face with a clean cloth. Then cover with a clean dry cloth. Cut the cord when it stops pulsating, using the disposable delivery kit, according to instructions. Wait for the placenta to deliver on its own. Make sure you and your baby are warm. Have the baby near you, dressed or wrapped and with head covered with a cap. Start breastfeeding when the baby shows signs of readiness, within the first hour of birth. Dispose of placenta DO NOT be alone for the 24 hours after delivery. DO NOT bath the baby on the first day.
M9
N4 LABOUR RECORD
N5 PARTOGRAPH
N6 POSTPARTUM RECORD
N7
N1
Referral records
RECORDS AND FORMS
N2
REFERRAL RECORD
WHO IS REFERRING NAME FACILITY ACCOMPANIED BY THE HEALTH WORKER RECORD NUMBER REFERRED DATE ARRIVAL DATE TIME TIME
WOMAN
NAME ADDRESS MAIN REASONS FOR REFERRAL
Emergency Non-emergency To accompany the baby
BABY
AGE NAME BIRTH WEIGHT MAIN REASONS FOR REFERRAL DATE AND HOUR OF BIRTH GESTATIONAL AGE
Emergency Non-emergency To accompany the mother
LAST (BREAST)FEED (TIME) TREATMENTS GIVEN AND TIME BEFORE REFERRAL TREATMENTS GIVEN AND TIME BEFORE REFERRAL
DURING TRANSPORT
DURING TRANSPORT
INFORMATION GIVEN TO THE WOMAN AND COMPANION ABOUT THE REASONS FOR
FEEDBACK RECORD
WHO IS REFERRING NAME FACILITY ACCOMPANIED BY THE HEALTH WORKER RECORD NUMBER REFERRED DATE ARRIVAL DATE TIME TIME
WOMAN
RECORDS AND FORMS INFORMATION AND COUNSELLING SHEETS
NAME ADDRESS MAIN REASONS FOR REFERRAL DIAGNOSES TREATMENTS GIVEN AND TIME TREATMENTS AND RECOMMENDATIONS ON FURTHER CARE
Emergency Non-emergency To accompany the baby
BABY
AGE NAME BIRTH WEIGHT MAIN REASONS FOR REFERRAL DIAGNOSES TREATMENTS GIVEN AND TIME TREATMENTS AND RECOMMENDATIONS ON FURTHER CARE DATE AND HOUR OF BIRTH GESTATIONAL AGE
Emergency Non-emergency To accompany the mother
WHEN
WHERE
WHEN
WHERE
Feedback record
N3
Labour record
RECORDS AND FORMS
N4
LABOUR RECORD
USE THIS RECORD FOR MONITORING DURING LABOUR, DELIVERY AND POSTPARTUM NAME ADDRESS DURING LABOUR ADMISSION DATE ADMISSION TIME TIME ACTIVE LABOUR STARTED TIME MEMBRANES RUPTURED TIME SECOND STAGE STARTS ENTRY EXAMINATION STAGE OF LABOUR NOT IN ACTIVE LABOUR NOT IN ACTIVE LABOUR HOURS SINCE ARRIVAL HOURS SINCE RUPTURED MEMBRANES VAGINAL BLEEDING (0 + ++) STRONG CONTRACTIONS IN 10 MINUTES FETAL HEART RATE (BEATS PER MINUTE) T (AXILLARY) PULSE (BEATS/MINUTE) BLOOD PRESSURE (SYSTOLIC/DIASTOLIC) URINE VOIDED CERVICAL DILATATION (CM) PROBLEM TIME ONSET TREATMENTS OTHER THAN NORMAL SUPPORTIVE CARE 1 2 3 4 5 6 7 8 9 10 11 12 ACTIVE LABOUR PLANNED MATERNAL TREATMENT AT OR AFTER BIRTH MOTHER BIRTH TIME OXYTOCIN TIME GIVEN PLACENTA COMPLETE NO TIME DELIVERED ESTIMATED BLOOD LOSS YES AT OR AFTER BIRTH NEWBORN LIVEBIRTH STILLBIRTH: FRESH YES MACERATED PLANNED NEWBORN TREATMENT AGE PARITY RECORD NUMBER
YES
PARTOGRAPH
USE THIS FORM FOR MONITORING ACTIVE LABOUR
10 cm
9 cm 8 cm
7 cm
6 cm 5 cm 4 cm
FINDINGS Hours in active labour Hours since ruptured membranes Rapid assessment B3-B7 Vaginal bleeding (0 + ++) Amniotic fluid (meconium stained) Contractions in 10 minutes Fetal heart rate (beats/minute) Urine voided T (axillary) Pulse (beats/minute) Blood pressure (systolic/diastolic) Cervical dilatation (cm) Delivery of placenta (time) Oxytocin (time/given) Problem-note onset/describe below TIME 1 2 3 4 5 6 7 8 9 10 11 12
Sample form to be adapted on june 13 2003
Partograph
N5
Postpartum record
RECORDS AND FORMS
N6
ADVISE AND COUNSEL
EVERY 5-15 MIN FOR 1ST HOUR 2 HR 3 HR 4 HR 8 HR 12 HR 16 HR 20 HR 24 HR MOTHER Postpartum care and hygiene Nutrition Birth spacing and family planning Danger signs Follow-up visits BABY Exclusive breastfeeding Hygiene, cord care and warmth Special advice if low birth weight Danger signs Follow-up visits
POSTPARTUM RECORD
MONITORING AFTER BIRTH TIME RAPID ASSESSMENT BLEEDING (0 + ++) UTERUS HARD/ROUND?
MATERNAL: BLOOD PRESSURE PULSE URINE VOIDED VULVA NEWBORN: BREATHING WARMTH NEWBORN ABNORMAL SIGNS (LIST) TIME FEEDING OBSERVED COMMENTS PLANNED TREATMENT MOTHER TIME TREATMENT GIVEN FEEDING WELL DIFFICULTY
PREVENTIVE MEASURES
FOR MOTHER Iron/folate Vitamin A Mebendazole Sulphadoxine-pyrimethamine Tetanus toxoid immunization RPR test result and treatment ARV FOR BABY Risk of bacterial infection and treatment BCG, OPV-0, Hep-0 RPR result and treatment TB test result and prophylaxis ARV
NEWBORN IF REFERRED (MOTHER OR NEWBORN), RECORD TIME AND EXPLAIN: IF DEATH (MOTHER OR NEWBORN), DATE, TIME AND CAUSE:
Sample form to be adapted. Revised on 25 August 2003.
N7
ABORTION Termination of pregnancy from whatever cause before the fetus is capable of extrauterine life. ADOLESCENT Young person 1019 years old. ADVISE To give information and suggest to someone a course of action. ANTENATAL CARE Care for the woman and fetus during pregnancy. ASSESS To consider the relevant information and make a judgement. As used in this guide, to examine a woman or baby and identify signs of illness. BABY A very young boy or girl in the first week(s) of life. BIRTH Expulsion or extraction of the baby (regardless of whether the cord has been cut). BIRTH AND EMERGENCY PLAN A plan for safe childbirth developed in antenatal care visit which considers the womans condition, preferences and available resources. A plan to seek care for danger signs during pregnancy, childbirth and postpartum period, for the woman and newborn.
BIRTH WEIGHT The first of the fetus or newborn obtained after birth. For live births, birth weight should preferably be measured within the first hour of life before significant postnatal weight loss has occurred, recorded to the degree of accuracy to which it is measured. CHART As used in this guide, a sheet presenting information in the form of a table. CHILDBIRTH Giving birth to a baby or babies and placenta. CLASSIFY To select a category of illness and severity based on a womans or babys signs and symptoms. CLINIC As used in this guide, any first-level outpatient health facility such as a dispensary, rural health post, health centre or outpatient department of a hospital. COMMUNITY As used in this guide, a group of people sometimes living in a defined geographical area, who share common culture, values and norms. Economic and social differences need to be taken into account when determining needs and establishing links within a given community.
BIRTH COMPANION Partner, other family member or friend who accompanies the woman during labour and delivery. CHILDBEARING AGE (WOMAN) 15-49 years. As used in this guide, also a girl 10-14 years, or a woman more than 49 years, when pregnant, after abortion, after delivery. COMPLAINT As described in this guide, the concerns or symptoms of illness or complication need to be assessed and classified in order to select treatment. CONCERN A worry or an anxiety that the woman may have about herself or the baby(ies). COMPLICATION A condition occurring during pregnancy or aggravating it. This classification includes conditions such as obstructed labour or bleeding. CONFIDENCE A feeling of being able to succeed. CONTRAINDICATION A condition occurring during another disease or aggravating it. This classification includes conditions such as obstructed labour or bleeding.
COUNSELLING As used in this guide, interaction with a woman to support her in solving actual or anticipated problems, reviewing options, and making decisions. It places emphasis on provider support for helping the woman make decisions. DANGER SIGNS Terminology used to explain to the woman the signs of life-threatening and other serious conditions which require immediate intervention. EMERGENCY SIGNS Signs of life-threatening conditions which require immediate intervention. ESSENTIAL Basic, indispensable, necessary. EXCLUSIVE BREASTFEEDING The infant takes only breastmilk and no additional food, water or other fluids (with the exception of vitamins and medicines if needed). FACILITY A place where organized care is provided: a health post, health centre, hospital maternity or emergency unit, or ward. FAMILY Inludes relationships based on blood, marriage, sexual partnership, and adoption, and a broad range of groups wose bonds are based on feelings of trust mutual support, and a shared destiny.
Glossary
GLOSSARY AND ACRONYMS
FOLLOW-UP VISIT A return visit requested by a health worker to see if further treatment or referral is needed. GESTATIONAL AGE Duration of pregnancy from the last menstrual period. In this guide, duration of pregnancy (gestational age) is expressed in 3 different ways:
Trimester Months First Second Third less than 4 months 4-6 months 7-9+ months Weeks less than 16 weeks 16-28 weeks 29-40+ weeks
prevention, detection and management of complications in the context of her environment and according to her wishes. LABOUR As used in this guide, a period from the onset of regular contractions to complete delivery of the placenta. LOW BIRTH WEIGHT BABY Weighing less than 2500 g at birth. MATERNITY CLINIC Health centre with beds or a hospital where women and their newborns receive care during childbirth and delivery, and emergency first aid. MISCARRIAGE Premature expulsion of a non-viable fetus from the uterus. MONITORING Frequently repeated measurements of vital signs or observations of danger signs. NEWBORN Recently born infant. In this guide used interchangeable with baby. PARTNER As used in this guide, the male companion of the pregnant woman (husband, free union) who is the father of the baby or the actual sexual partner.
POSTNATAL CARE Care for the baby after birth. For the purposes of this guide, up to two weeks. POSTPARTUM CARE Care for the woman provided in the postpartum period, e.g. from complete delivery of the placenta to 42 days after delivery. PRE-REFERRAL Before referral to a hospital. PREGNANCY Period from when the woman misses her menstrual period or the uterus can be felt, to the onset of labour/elective caesarian section or abortion. PREMATURE Before 37 completed weeks of pregnancy. PRETERM BABY Born early, before 37 completed weeks of pregnancy. If number of weeks not known, 1 month early. PRIMARY HEALTH CARE* Essential health care accessible at a cost the country and community can afford, with methods that are practical, scientifically sound and socially acceptable. (Among the essential activities are maternal and child health care, including family planning; immunization; appropriate treatment of common diseases and injuries; and the provision of essential drugs).
PRIMARY HEALTH CARE LEVEL Health post, health centre or maternity clinic; a hospital providing care for normal pregnancy and childbirth. PRIORITY SIGNS Sins of serious conditions which require interventions as soon as possible, before they become life-threatening. QUICK CHECK A quick check assessment of the health status of the woman or her baby at the first contact with the health provider or services in order to assess if emergency care is required. RAPID ASSESSMENT AND MANAGEMENT Systematic assessment of vital functions of the woman and the most severe presenting signs and symptoms; immediate initial management of the life-threatening conditions; and urgent an safe referral to the next level of care. REASSESSMENT As used in this guide, to examine the woman or baby again for signs of a specific illness or condition to see if she or the newborn are improving. RECOMMENDATION Advice. Instruction that should be followed.
GRUNTING Soft short sounds that a baby makes when breathing out. Grunting occurs when a baby is having difficulty breathing. HOME DELIVERY Delivery at home (with a skilled attendant, a traditional birth attendant, a family member, or by the woman herself). HOSPITAL As used in this guide, any health facility with inpatient beds, supplies and expertise to treat a woman or newborn with complications. INTEGRATED MANAGEMENT A process of caring for the woman in pregnancy, during and after childbirth, and for her newborn, that includes considering all necessary elements: care to ensure they remain healthy, and
REFERRAL, URGENT As used in this guide, sending a woman or baby, or both, for further assessment and care to a higher level of care; including arranging for transport and care during transport, preparing written information (referral form), and communicating with the referral institution. REFERRAL HOSPITAL A hospital with a full range of obstetric services including surgery and blood transfusion and care for newborns with problems. REPLACEMENT FEEDING The process of feeding a baby who is not receiving breast milk with a diet that provides all the nutrients she/he needs until able to feed entirely on family foods. SECONDARY HEALTH CARE More specialized care offered at the most peripheral level, for example radiographic diagnostic, general surgery, care of women with complications of pregnancy and childbirth, and diagnosis and treatment of uncommon and severe diseases. (This kind of care is provided by trained staff at such institutions as district or provincial hospitals).
SHOCK A dangerous condition with severe weakness, lethargy, or unconsciousness, cold extremeties, and fast, weak pulse. It is caused by severe bleeding, severe infection, or obstructed labour. SIGN As used in this guide, physical evidence of a health problem which the health worker observes by looking, listening, feeling or measuring. Examples of signs: bleeding, convulsions, hypertension, anaemia, fast breathing. SKILLED ATTENDANT Refers exclusively to people with midwifery skills (for example, midwives, doctors and nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose or refer obstetric complications. Traditional birth attendant not included. For the purposes of this guide, a person with midwifery skills who: has acquired the requisite qualifications to be registered and/or legally licensed to practice training and licensing requirements are country-specific; May practice in hospitals, clinics, health units, in the home, or in any other service setting. Is able to do the following: give necessary care and advice to women during pregnancy and postpartum and for their newborn infants;
conduct deliveries on her/his own and care for the mother and newborn; this includes provision of preventive care, and detection and appropriate referral of abnormal conditions. provide emergency care for the woman and newborn; perform selected obstetrical procedures such as manual removal of placenta and newborn resuscitation; prescribe and give drugs (IM/IV) and infusions to the mother and baby as needed, including for post-abortion care. provide health information and counselling for the woman, her family and community. SMALL BABY A newly born infant born preterm and/or with low birth weight. STABLE Staying the same rather than getting worse. STILLBIRTH Birth of a baby that shows no signs of life at birth (no gasping, breathing or heart beat). SURVEILLANCE, PERMANENT Continuous presence and observation of a woman in labour.
SYMPTOM As used in this guide, a health problem reported by a woman, such as pain or headache. TERM, FULL-TERM Word used to describe a baby born after 37 completed weeks of pregnancy. TRIMESTER OF PREGNANCY See Gestational age. VERY SMALL BABY Baby with birth weight less than 1500g or gestational age less than 32 weeks. WHO definitions have been used where possible but, for the purposes of this guide, have been modified where necessary to be more appropriate to clinical care (reasons for modification are given). For conditions where there are no official WHO definitions, operational terms are proposed, again only for the purposes of this guide.
Glossary
Acronyms
GLOSSARY AND ACRONYMS
Aronyms
ACRONYMSc
LBW Low birth weight: birth weight less than 2500 g. LMP Last menstrual period: a date from which the date of delivery is estimated. MTCT Mother-to-child transmission of HIV. NG Naso-gastric tube, a feeding tube put into the stomach through the nose. ORS Oral rehydration solution. OPV-0 Oral polio vaccine. To prevent poliomyelitis, OPV-0 is given at birth. QC A quick check assessment of the health status of the woman or her baby at the first contact with the health provider or services in order to assess if emergency care is required. PAL Practical approach to lung health guidelines RAM Systematic assessment of vital functions of the woman and the most severe presenting signs and symptoms; immediate initial management of the life-threatening conditions; and urgent and safe referral to the next level of care. RPR Rapid plasma reagin, a rapid test for syphilis. It can be performed in the clinic. STI Sexually transmitted infection. TBA A person who assists the mother during childbirth. In general, a TBA would initially acquire skills by delivering babies herself or through apprenticeship to other TBAs. TT An immunization against tetanus VCT Voluntary counselling and testing for HIV > More than < Equal or more than > Less than < Equal or less
AIDS Acquired immunodeficiency syndrome, caused by infection with human immunodeficiency virus (HIV). AIDS is the final and most severe phase of HIV infection. ANC Care for the woman and fetus during pregnancy. ARV Antiretroviral drug, a drug to treat HIV infection. As used in this guide, a drug used to prevent mother-to-child transmission of HIV. BCG An immunization to prevent tuberculosis, given at birth. BP Blood pressure. BPM Beats per minute. FHR Fetal heart rate. Hb Haemoglobin. HB-1 Vaccine given at birth to prevent hepatitis B. HMBR Home-based maternal record: pregnancy, delivery and interpregnancy record for the woman and some information about the newborn. HIV Human immunodeficiency virus. HIV is the virus that causes AIDS. INH Isoniazid, a drug to treat tuberculosis. IV Intravenous (injection or infusion). IM Intramuscular injection. IU International unit. IUD Intrauterine device. LAM Lactation amenorrhea.